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OF   TH  E 

•School  of  Medicine 


i. 


defaced,  while  in  the  possession  of^a  mem* 
ber,  he  shall  be  finable  at  the  discretion 
of  the  Library  Directors',  or,  at  his  option, 
may  furnish  such  a  copy,  or  edition  of  the 
same  work  as  shall  be  acceptable  to  said 
directors. 

i  VJ  c  If.a,.ly  ,nfmber  on  returning  a  Imok 
shall  find  that  there  has  been  no  applica- 
tion lor  it  while   in   his  possession,  and 


i  cTcry  uesci ipuon  Belonging 
to  tlie  library.  & 

XI.  Scarce  and  valuable  books,  the  loss 
of  winch  it  would  be  difficult  to  repair, 
shall  be  marked  in  the  catalogue  with  an 
asterisk,  to  indicate  that  they  will  not  be 
let  out  of  the  library  without  the  approba- 
tion of  two  of  the  directors.  In  the  event 
of  the  librarian  being  a  director,  he  is  un- 
derstood not  to  be  included. 


-4 


L 


*J 


*. 


CAREY  &  LEA 

HAVE  RECENTLY  PUBLISHED  THE  FOLLOWING 

VALUABLE  WORKS. 


I. 
HISTORY  OF  ENGLAND, 

Bi  Sib  JAMES  MACKINTOSH,  Noll. 

BfelHS     A     lMIHTlON     HI 

The  Cabinet  Ilistory  of  the  British  Islands, 

r.i;  Mi  \(, 
HISTORY  of  ENGLAND.  By  Sir  James  Mackintosh,  Vol.  I. 
"  Our  anticipations  of  this  volume  were  certainh  verj  highly  raised,  and  un- 
likesuch  anticipations  in  general,  the)  have  not  been  disappointed.    A  philo- 
lophical  spirit,  a  nervous  style,  and  a  full  knowledge  of  the  subji  ot,  acquired  by 
considerable  research  into  the  works  of  preceding  chroniclers  and  historians, 
eminent!;  distinguish  this  popular  abridgment,  and  cannot  fail  to  recommend  it 
to  universal  approbation.    In  continuing  his  work M  he  lias  begun,  Sir  Jama 
Mackintosh  will  confer  a  great  benefit  on  his  country."— Lund.  Lit.  Gazette. 
BISTORT  of  SCOTLAND.  By  Sir  Wai.teii  Scott,  2  vols. 
HISTORY  of  IRELAND.    By  Thomas  Mooes,  1  vol. 

II.  HISTORY  of  SCOTLAND.    By  Sir  Walter 

Scott,  Hart,  in  2  vols.  12mo. 

1  he  History  of  Scotland,  by  Sir  Walter  Scott,  we  do  not  hesitate  to  declare, 
will  be,  if  possible,  more  <  xtensively  read,  than  the  most  popular  work  of  fiction, 
by  the  same  prolific  author,  and  for  this  obvious  reason:  it  combines  much  of  the 
brilliant  colouring  of  the  Ivanhoe  pictures  of  by-pone  manners,  and  all  the 
graceful  facility  of  style  and  picturesqueness  of  description  ofbii  other  charm- 
ing romances,  with  a  minute  fidelity  to  the  tacts  of  history.and  a  searching  scru- 
tiny into  their  authenticity  and  relative  value,  which  might  put  to  the  blush  Mr. 
Hume  and  other  professed  historians.  Such  is  the  magic  charm  of  Sir  Walter 
Scott's  pen,  it  his  only  to  touch  the  simplest  incident  of  every  day  life,  and  it 
Starts  up  invested  with  all  the  interest  of  a  scene  of  romance;  and  yet  such  is  his 
fidelity  to  the  text  of  nature,  that  the  knights,  and  ecrfs,  and  collared  fools  with 
whom' his  inventive  genius  has  peopled  so  many  volumes,  are  regarded  by  us  as 
not  mere  creations  of  fancy,  but  as  real  flesh  and  blood  existences,  with  all  the 
.  feelings  and  errors  of  common  place  humanity."—  Lit.  Gaz. 

ILL   CLARENCE 5  a  Tide  of  our  own  Times.   By 
the  Author  of  Redwood,  Hope  Leslie,  &c.  In  two  volumes. 

IV.   CAMDEN;  a  Tale  of  the  South.   In  two  Vols. 
V-  ATLANTIC  SOUVENIR, 

FOR  1831. 

Embellishments.— \.  Frontispiece.  The  Shipwrecked  Family,  engraved  by 
Ellis,  from  a  picture  by  Burnet — 2.  Shipwreck  of  Fort  RougeCalais,  engrav- 
ed by  Ellis,  from  a  picture  by  Stanfield.— 3.  Infancy,  engraved  by  Kelly,  from 
a  picture  by  Sir  Thomas  Lawrence.—- 1.  Lady  Jane  Grey, engraved  by' Kelly, 
from  a  picture  by  Leslie.— 5.  Three  Score  and  Ten,  engraved  by  Kearny,  from 
■  picture  by  Burnet.— 6.  The  Hour  of  Rest,  engraved  by  Kelly,' from  a  picture 
by  Burnet.— 7.  The  Minstrel,  engraved  by  Ellis,  from  a  picture  by  Leslie.— 8. 
Arcadia,  engraved  by  Kearny,  from  a  picture  by  Cockerell. — °.  The  Fisherman's 
Return, engraved  by  Nagle.  from  a  picture  by  Collins.— 10.  The  Marchioness 
of  Carmarthen,  granddaughter  of  Charles  Carroll  of  Carrollton,  engraved  by  Ill- 
man  and  Pillbrow  from  a  picture  by  Mrs.  Mir.— 11.  Morning  among  the  Hills, 
engraved  by  Hatch, from  a  picture  by  Doughty. — 12.  Los  Musicos,  engraved  by 
Ellis,  from  a  picture  bv  Watteau.  (Heart]  ready.) 

VI.   The  POETICAL  WORKS  of  CAMPBELL, 
ROGERS,  MONTGOMERY,  LAMBE,  and  KIRKE  WHITE, 

beautifullv  printed,  1vol.  8vo.  to  match  Bvron,  Scott,  Moore,  &c. 

1 


2  Valuable  Works 

VII.  SKETCHES  of  CHINA,  with  Illustrations 

from  Original  Drawings.  By  W.  W.  Wood,  in  1  vol.  12mo. 

"  The  residence  of  the  author  in  China,  during  the  years  1826-7-8  and  9,  has 
enabled  him  to  collect  much  very  curious  information  relative  to  this  singular 
people,  which  he  has  embodied  in  his  work;  and  will  serve  to  gratify  the  curi- 
osity of  many  whose  time  or  dispositions  do  not  allow  them  to  seek,  in  the  volu- 
minous writings  of  the  Jesuits  and  early  travellers,  the  information  contained 
in  the  present  work.  The  recent  discussion  relative  to  the  renewal  of  the  East 
India  Company's  Charter,  has  excited  much  interest;  and  among  ourselves,  the 
desire  to  be  further  acquainted  with  the  subjects  of  '  the  Celestial  Empire'  has 
been  considerably  augmented." 

VIII.  FALKLAND,  a  Novel,  by  the  Author  of 
Pelham,  &c.  1  vol.  12mo. 

IX.  MEMOIR  on  the  TREATMENT  of  VENE- 
REAL DISEASES  WITHOUT  MERCURY,  employed  at  the 
Military  Hospital  of  the  Val-de-Grace.  Translated  from  the 
French  of  H.  M.  J.  Desruelles,  M.  D.  &c.  To  which  is  added, 
Observations  by  G.  J.  Guthrie,  Esq.  and  various  documents, 
showing"  the  results  of  this  Mode  of  Treatment,  in  Great  Bri- 
tain, France,  Germany,  and  America,  1  vol.  8vo. 

X.  PRINCIPLES   of   MILITARY   SURGERY, 

comprising-  Observations  on  the  Arrangements,  Police,  and 
Practice  of  Hospitals,  and  on  the  History,  Treatment,  and 
Anomalies  of  Variola  and  Syphilis;  illustrated  with  cases  and 
dissections.  By  John-  Hexnex,  M.  D.  F.  R.  S.  E.  Inspector  of 
Military  Hospitals — first  American  from  the  third  London  edi- 
tion, with  Life  of  the  Author,  by  his  son,  Dr.  Joux  Hexxex. 

"The  value  of  Dr.  Hennen's  work  is  too  well  appreciated  to  need  any  praise 
of  ours.  We  wwe  only  required  then,  to  bring  the  third  edition  b.  fore' the  no- 
tice of  our  readers;  and  having  done  this,  we  shall  merely  add,  that  the  volume 
merits  a  place  in  every  library,  and  that  no  military  surgeon  ought  to  be  without 
it."— Medical  Gazette. 

"  It  is  a  work  of  supererogation  for  us  to  eulogize  Dr.  Hennen's  Military  Sur- 
gery; there  can  be  no  second  opinion  on  its  merits.  It  is  indispensable  to  the  mi- 
litary and  naval  surgeon."— London  Medical  and  Surgical  Journal. 

XL  PATHOLOGICAL  and  PRACTICAL  RE- 
SEARCHES on  DISEASES  of  the  STOMACH,  the  IN- 
TESTINAL CANAL,  the  LIVER,  and  other  VISCERA  of  the 
ABDOMEN.   By  .Unix  Arercromrif.,  M.  D. 

"  We  have  now  closed  a  very  long  review  of  a  very  valuable  work,  and  al- 
though we  have  endeavoured  to  condense  into  our  pages  a  great  mass  of  impor- 
tant matter,  we  feel  that  our  author  has  not  yet  received  justice."— Med.  Chir. 
Review. 

XII.  A     COLLECTION     of     COLLOQUIAL 

PHRASES  on  every  Topic  necessary  to  maintain  Conversation, 
arranged  under  different  heads,  with  numerous  remarks  on 
the  peculiar  pronunciation  and  use  of  various  words — the 
whole  so  disposed  as  considerably  to  facilitate  the  acquisition 
of  a  correct  pronunciation  of  the  French.  By  A.  Boluar.  One 
vol.  18mo. 

XIII.  A    SELECTION    of    ONE    HUNDRED 

PERRIN'S  FABLES,  accompanied  by  a  Key,  containing-  the 
text,  a  literal  and  free  translation,  arranged  in  such  a  manner 
as  to  point  out  the  difference  between  the  French  and  the 
English  idiom,  also  a  figured  pronunciation  of  the  French,  ac- 
cording to  the  best  French  works  extant  on  the  subject;  the 


Published  by  Carey  fy  Lea.  3 

I  by  a  short  treatise  on  (he  sounds  of  the  French 
language,  compared  with  those  of  the  English. 

XIV.  The  First  Eight  Books  of  the  ADVENTURES 
of  TELEMACHUS,  accompanied  by  a  Key  to  facilitate  the 

tlation  of  the  work. 

XV.  A  TREATISE  on  PATHOLOGICAL  ANA- 

IV,  b\  Wixxiam  E.  HoitsKii,  M.  1>.  Adjunct  Professor  of 
Anatomy  "in  the  University  of  Pennsylvania. 

onscientiously  commend  it  to  the  members  of  the  profession, as  a 

satisfactory,  interesting,  mxl  hutructive  view  of  the  subjects  discussed,  and 

tl  adapted  to  aid  them  in  forming  a  correct  appreciation  of  the  dueased 

called  on  i«j  relieve.'  I  Journal  <>J  the  Medical 

.  'a  New  Edition  ofa  TREATISE  of  SPECIAL 

and  GEN  EH  \l.  ANATOMY,  by  the  same  author,  2  vols.  8vo. 

XVII.  COXE'S  AMERICAN  DISPENSATORY, 

containing  the  Natural,  Chemical,  Pharmaceutical  and  Medical 
History  of  the  different  substances  employed  in  medicine,  to- 
gether with  the  operations  of  Pharmacy  illustrated  and  ex- 
plained, according  to  the  principles  of  modern  Chemistry.  To 
which  are  added  Toxicological  and  other  tables,  the  prescrip- 
tions for  Patent  .Medicines,  and  various  Miscellaneous  Prepa- 
rations. Eighth  Edition,  Improved  and  greatly  Enlarged.  By 
John  Rxsmab  Coxt,  M.  1).  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.    In  1  vol.  8vo. 

XVIII.  An  ESSAY  o'n  REMITTENT  and  INTER- 
MITTENT DISK  ASES,  including  genetically  Marsh  Fever  and 
Neuralgia — comprising  under  the  former,  various  anomalies, 
obscurities,  and  consequences,  and  under  a  new  systematic 
view  of  the  latter,  treating  of  tic  douloureux,  sciatica,  head- 
ache, ophthalmia,  tooth-ache,  palsy,  and  many  other  modes  and 
consequences  of  this  generic  disease;  by  John-  Macccuoch, 
If.  D.,  F.  R.  8.  fcc  &c.  Physician  in  Ordinary  to  his  Royal 
Highness  Prince  Leopold,  of  Saxe  Cobourg. 

"  Dr.  Maeculloeh  is  a  great  philosopher  and  logician.  His  views  are  calculated 
to  do  mneti  good.  We  bare  therefore  taken  great  ]>;;in->  to  concentrate  and  dif- 
fuse them  widely  through  the  profession.  Nothing  but  a  strong  conviction  that 
the  work  before  ns  contains  a  multitude  of  valuable  gi  ms.  could  have  induced  us 
rtow  so  much  labour  on  the  review.  In  i\  ndenng  Dr.  Macculloch'a  work 
more  accessible  to  the  profession,  we  are  conscious  that  we  are  doing  the  state 
same  sen  ice.M— Med.  Cnir.  Review. 

"We  most  Strongly  recommend  Dr.  Maceulloch's  treatise  to  the  attention  of 
our  medical  brethn  n,  as  presenting  a  most  valuable  man  of  information,  on  a 
_-uosf  important  subjt  ct."— Am.  Med.  and  Phut.  Journal. 

XIX.  WISTAR'S  ANATOMY,  fifth  edition,  2 
vols.  8vo. 

XX.  The  ANATOMY,  PHYSIOLOGY,  and  DIS- 
EASES of  the  TEETH.  By  Thomas  Bkli,  F.  R.  S.,  F.  L.  S. 
ice.  In  1  vol.  8vo.  with  plates. 

11  Mr.  Bell  has  evidently  endeavoured  to  construct  a  work  of  reference  for  the 
practitioner,  and  a  text-book  for  the  student,  containing  a  '  plain  and  practical 
digest  of  the  information  at  present  possessed  on  the  subject,  and  results  of  the 
author's  own  investigations  and  experience.'  "»••**  \\\.  mast  now  take  leave 
of  Mr.  Bell,  whose  work  we  have  no  doubt  will  become  a  class  book  on  the  im- 
portant subject  of  dental  $\iY%vv\."—Mcdico-C/iirurgical  Revit-ii: 

XXI.  MORALS  of  PLEASURE,  illustrated  by 
stories  designed  for  Young  Persons,  in  1  vol.  12mo. 


4  Valuable  Works 

"  The  style  of  the  stories  is  no  less  remarkable  for  its  ease  and  gracefulness, 
than  for  the  delicacy  of  its  humour,  and  its  beautiful  and  at  times  affecting'  sim- 
plicity. A  lady  must  have  written  it-for  it  is  from  the  bosom  of  woman  alone, 
that  such  tenderness  of  feeling  and  such  delicacy  of  sentiment— such  sweet  les- 
sons ot  morality—such  deep  and  pure  streams  of  virtue  and  piety,  gush  forth  to 
cleanse  the  juvenile  mind  from  ihe  grosser  impurities  of  our  nature!  and  prepare 
the  young  for  lives  of  usefulness  here,  and  happiness  hereafter.  We  advise  pa- 
rents of  young  families  to  procure  this  little  book-assuring  them  that  it  will 
nave  a  tendency  to  render  their  offspring  as  sweet  as  innocent,  as  innocent  as 
gay,  as  gay  as  happy.  It  is  dedicatad  by  the  author  '  to  her  young  Bedford 
tnenus,  Anna  and  Mana  Jay'— but  who  this  fair  author  is,  we  cannot  even  guess. 
H  e  would  advise  some  sensible  educated  bachelor  to  find  out."— N.  T.  Com.  Adv. 

XXII.  The  PRACTICE  of  PHYSIC,  by  W.  P. 
Dewees,  M.D.  Adjunct  Professor  of  Midwifery  in  the  University 
of  Pennsylvania,  2  vols.  8vo. 

The  profession  need  not  be  informed  how  much  a  work  like  that  now  pub- 
lished was  wanted.  It  has  been  the  particular  object  of  the  author  to  endeavour 
to  accommodate  the  mode  of  managing  the  diseases  of  which  he  treats  to  the 
many  pathological  discoveries  recently  made,  both  in  this  countrv  and  in  Europe; 
and  having  also  availed  himself  of  his  long  experience,  he  trusts  that  his  work 
will  remove  many  of  the  embarrassments  experienced  bv  practitioners. 

XXIII.  DEWEES  on  the  DISEASES  of  CHIL- 
DREN. Third  edition.  In  8vo. 

The  objects  of  this  work  are,  1st,  to  teach  those  who  have  the  charge  of  chil~ 
dren,  either  as  parent  or  guardian,  the  most  approved  methods  of  securing  and! 
improving  their  physical  powers.  This  is  attempted  by  pointing  out  the  du- 
ties which  the  parent  or  the  guardian  owes  for  this  purpose,  to  tins  interesting, 
but  helpless  class  of  beings,  and  the  manner  by  which  their  duties  shall  be  ful- 
filled: And  2d,  to  render  available  a  long  experience  to  these  objects  of  our  af- 
fections, when  they  become  diseased.  In  attempting  this,  the  author  has  avoided 
as  much  as  was  possible,  "technicality;"  and  has  given,  if  he  does  not  flatter  him- 
self too  much,  to  each  disease  of  which  he  treats,  its  appropriate  and  designat- 
ing characters,  with  a  fidelity  that  will  prevent  any  two  being  confounded,  to- 
gether with  the  best  mode  of  treating  them,  that  either  his  own  experience  or 
that  of  others  has  suggested. 

XXIV.  DEWEES  on  the  DISEASES  of  FEMALES. 

Second  edition  with  additions.     In  8vo. 

XXV.  DEWEES'S  SYSTEM  of  MIDWIFERY. 

Fourth  edition,  with  additions. 

XXVI.  CHAPMAN'S  THERAPEUTICS  and  MA. 
TERIA  MEDICA.     Fifth  edition,  with  additions. 

XXVII.  The  ATLANTIC  SOUVENIR,  for  1 830,  in 
elegant  fancy  leather  binding-,  and  with  numerous  embellish- 
ments by  the  best  Artists. 

The  publishers  have  spared  neither  pains  nor  expense  in  endeavouring  to 
render  this,  their  fifth  annual  volume,  still  more  worthy  the  high  degree  of  fa- 
vour which  its  predecessors  have  enjoyed.  All  the  impressions  being  from  steel 
render  them  equally  perfect,  and  the  binding  being  a  fancy  leather,  the  whole 
will  be  rendered  more  permanent.  In  the  list  of  Authors  will  be  found  many 
of  the  most  distinguished  writers  in  this  country. 

A  few  copies  remain  unsold  of  the  ATLANTIC  SOUVENIR, 
a  Christmas  and  New  Year's  Present  for  1827,  1828,  and  1829, 
with  numerous  embellishments  bv  the  best  Artists. 

XXVIII.  A  CHRONICLE  of  the  CONQUEST  of 

GRENADA,  by  Wasitixgtox  Irvixg,  Esq.  in  2  vols. 

"  On  the  whole,  this  work  will  sustain  the  high  fame  of  Washington  Irving. 
It  fills  a  blank  in  the  historical  library  which  ought  not  to  have  remained  sb 
long  a  blank.  The  language  throughout  is  at  once  chaste  and  animated;  and 
the  narrative  may  be  said,  like  Spencer's  Fairy  Queen,  to  present  one  long  gal- 
lery of  splendid  pictures.  Indeed,  we  know  no  pages  from  which  the  artist  is 
more  likely  to  derive  inspiration,  nor  perhaps  are  there  many  incidents  in  lite- 
rary  history  more  surprising  than  that  this  antique  and  chivalrous  story  should 
have  been  for  the  first  time  told  worthily  by  the  pen  of  an  American  and  a  re* 
publican." — London  Literary  Gazette* 


Published  by  Carey  «$•  Lea.  5 

Recently  published  new  Editions  of  the  following  works 
by  the  .same.  Author, 

Tin:  SKETCH  BOOK,  2  vols.  12 ma 

KNICKERBOCKER'S  HISTORY  of  NEW  YORK,  2  vols. 
12mo. 

BRACEBRIDGE  HALL,  2  vols.  12mo. 

TALES  of  a  TRAVELLER,  2  vols.  12mo. 

XXIX.  NEUMAN'S  SPANISH  and  ENGLISH 
DICTIONARY,  new  Edition. 

XXX.  The  WISH-TON-WISH,  by  the  Author  of 
the  Spv,  Pioneers,  Rxa  Royxb,  &c.  in  2  vols.  Umo. 

u  We  can  conceive  few  periods  better  calenlaa  d  to  offer  a  promising  field  to 
the  novelist  Mian  that  which  these  pages  illustrate; — the  noingnng  of  w  ildt  H  ad- 
venture »  ith  the  most  plodding  industry — the  severe  spirit  of  the  religion  of  the 
first  American  lettlen — the  feelings  of  aoux  hold  and  home  at  variance  with  all 
earner  ataooiationa  of  country — the  magnificence  of  the  ieenery  by  which  they 
ntrrotmded — their  neighbourhood  to  that  most  pietnroqoe  and  extraordi- 
nary ofneople  we  call  savages; — these,  lurelr,  are  materials  for  the  novelist,  and 
in  Sir.  Cooper's  hands  they  nave  lost  none  of  their  in  ten  st.  We  shall  not  attempt 
to  detail  the  narrative,  but  only  say  it  is  well  worthy  of  the  high  reputation  of 
its  author.  All  the  more  serious  scenes  are  worked  an  to  the  highest  pitch  of 
excitement;  if  any  where  we  have  to  complain  of  aught  like  failure,  it  is  in  the 
lighter  parts,  and  some  of  the  minor  details,  which  are  occasionally  spun  out 
too  much."—  London  Literary  Gazette. 

':  Editions  of  the  following  Works  by  the  same 
Author. 
The  RED  ROVER,  in  2  vols.  12mo. 
The  SPY,  2  vols.  12mo. 
The  PIONEERS,  2  vols.  12mo. 
The  PILOT,  a  Tale  of  the  Sea,  2  vols.  12mo. 
LIONEL  LINCOLN,  or  the  LEAGUER  of  BOSTON,  2  vols. 
The  LAST  of  the  MOHICANS,  2  vols.  12mo. 
The  PRAIRIE,  2  vols.  12mo. 

XXXI.  A  TOUR  in  AMERICA,  by  Basil  Hall, 
Captain,  R.  N.  in  2  vols.  12mo. 

XXXII.  AMERICAN  ORNITHOLOGY,  or  NA- 
TURAL HISTORY  of  BIRDS  inhabiting  the  UNITED 
STATES,  by  Coari.es  Luciax  Boxaparte;  designed  as  a 
continuation  of  Wilson's  Ornithology,  vols.  I.,  II.  and  HI. 

*#*  Gentlemen  who  possess  Wilson,  and  are  desirous  of  ren- 
dering the  work  complete,  are  informed  that  the  edition  of 
this  work  is  very  small,  and  that  but  a  very  limited  number  of 
copies  remain  unsold. 

XXXI II.  The  AMERICAN  QUARTERLY  RE- 
VIEW, No.  XV.  Contents.— The  Gulistan  of  Sadi.— Napoleon 
and  Bourienne. — Anthon's  Horace. — Falkland  and  Paul  Clif- 
ford.— Tanner's  Indian  Narrative. — Dramatic  Literature. — 
British  Debate  concerning  Mexico. — Sunday  Mails. — Life  of 
Sir  Thomas  Munro. — Fanatical  Guides. — Terms,  Jive  dollars 
per  annum. 

XXXIV.  The  AMERICAN  JOURNAL  of  the  ME- 
DICAL SCIENCES,  No.  XII.  for  August,  1830.  Among  the 
Collaborators  of  this  work  are  Professors  Bigelow,  Channing, 
Chapman,  Coxe,  Davidge,  De  Butts,  Dewees,  Dickson,  Dud- 

!• 


6  Valuable  Works 

ley,  Francis,  Gibson,  Godman,  Hare,  Henderson,  Horner, 
Hosack,  Jackson,  Macneven,  Mott,  Mussey,  Physick,  Potter, 
Sewall,  Warren,  and  Worthington ;  Drs.  Daniell,  Emerson, 
Fearn,  Griffith,  Hays,  Hayward,  Ives,  Jackson,  King-,  Moultrie, 
Spence,  Ware,  and  Wright. — Terms,  Jive  dollars  per  annum. 

XXXV.  EVANS'S  MILLWRIGHT  and  MIL- 
LER'S GUIDE.  New  edit,  with  additions,  by  Dr.  T.  P.  Jones. 

XXXVI.  HUTIN'S  MANUAL  of  PHYSIO- 
LOGY, in  12mo. 

XXXVII.  HISTORICAL,  GEOGRAPHICAL, 
and  STATISTICAL  AMERICAN  ATLAS,  folio. 

XXXVIII.  MANUAL  of  MATERIA  MEDICA 
and  PHARMACY.  By  H.M.  Edwards,  M.D.  andP.VAVAssEtJR, 
M.  D.  comprising  a  Concise  Description  of  the  Articles  used 
in  Medicine;  their  Physical  and  Chemical  Properties;  the  Bo- 
tanical Characters  of  the  Medicinal  Plants;  the  Formulae  for  the 
Principal  Officinal  Preparations  of  the  American,  Parisian, 
Dublin,  Edinburgh,  8cc.  Pharmacopoeias;  with  Observations  on 
the  Proper  Mode  of  Combining  and  Administering  Remedies. 
Translated  from  the  French,  with  numerous  Additions  and 
Corrections,  and  adapted  to  the  Practice  of  Medicine  and  to 
the  Art  of  Pharmacy  in  the  United  States.  By  Joseph  Togno, 
M.  D.  Member  of  the  Philadelphia  Medical  Society,  and  E. 
Durand,  Member  of  the  Philadelphia  College  of  Pharmacy. 

"  It  contains  all  the  pharmaceutical  information  that  the  physician  can  desire, 
and  in  addition,  a  larger  mass  of  information,  in  relation  to  the  properties,  &c. 


of  the  different  articles  and  preparations  employed  in  medicine,  than  any  of  the 
dispensatories,  and  we  think  will  entirely  supersede  all  these  publications  in  the 
library  of  the  physician" — Am.  Joum.  of  the  Medical  Sciences. 

XXXIX.  An  EPITOME  of  the  PHYSIOLOGY, 
GENERAL  ANATOMY,  and  PATHOLOGY  of  BICHAT,  by 
Thomas  Henderson,  M.  D.  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  in  Columbia  College,  Washington  City.  1 
vol.  8vo. 

'"  The  epitome  of  Dr.  Henderson  ought  and  must  find  a  place  in  the  library 
physician  desirous  of  useful  knowledge  for  himself,  or  of  being  instru- 


mental in  imparting  it  to  others,  whose  studies  he  is  expected  to  superintend.-'- 
Meir 


of  erery  physician  desirous 
mental  in  imparting  it  to  otl 
North  American  Medical  and  Surgical  Journal,  No.  15. 

XL.  ADDRESSES  DELIVERED  on  VARIOUS 

PUBLIC  OCCASIONS,  by  John  D.  Godman,  M,  D.  late 
Professor  of  Natural  History  to  the  Franklin  Institute,  Profes- 
sor of  Anatomy,  &c.  in  Rutgers  College,  &c.  &c.  With  an 
Appendix,  containing  a  Brief  Explanation  of  the  Injurious 
Effects  of  Tight  Lacing  upon  the  Organs  and  Functions  of 
Respiration,  Circulation,  Digestion,  &c.  1  vol.  8vo. 

XLI.  ELLIS'  MEDICAL  FORMULARY.  The 
Medical  Formulary,  being  a  collection  of  prescriptions  de- 
rived from  the  writings  and  practice  of  many  of  the  most  emi- 
nent physicians  in  America  and  Europe.  To  which  is  added 
an  Appendix,  containing  the  usual  dietetic  preparations  and 
antidotes  for  poisons.  The  whole  accompanied  with  a  few 
brief  pharmaceutic  and  medical  observations.  By  Ben  jam  in 
Ellis,  M.  D.  Professor  of  Materia  Medica  and  Pharmacy  in  the 
Philadelphia  College  of  Pharmacy.  2d  edition,  with  additions. 


Published  by  Carey  £  Lea.  7 

u  A  small  ami  v<  r\  mm  Jul  volume  lias  been  ivcmily  putmssV  d  in  tliii  ii' 

■  ill.  Medical  Formulary.'  W<  beJien  that  this  rohnne  will  meet  with  a 
cordial  welcome  from  the  medical  [inblic.  We  would  especially  ivcunnm  nd  it 
to  our  brethren  in  distant  parti  of  the  country,  whose  insulated  situation-  may 
prevent  them  from  li  tvine  access  to  the  man)  authorities  which  hare  been  con- 
sulted in  arranging  mutenals  for  this  work."—  PhU,  Med. and  Plnjs.  Jour. 

ALII.  ELEMENTS  ol  PHYSICS,  or  NATU- 
RAL PHILOSOPHY,  GENERAL  and  MEDICAL,  explained 

independently  of  TECHNICAL  M  vnii.M  ATlCS,  and  con- 
taining- New  Disquisitions  and  Practical  Suggestions.  By 
Nkil  Aumitt,  M.  I).  First  American  from  the  third  London 
edition,  with  additions,  by  l<\\*   ELiTS,  M.  1). 

*„•  Of  thi->  work  four  editions  have  been  printed  in  Midland  in  a  very  short 
tin ie.    All  the  Reviews  speak  of  it  m  the  lii^-liii  st  terms. 

XLI11.  LA  FAYETTEin  AMERICA,  in  island 

1825;  or  a  Journal  of  a  Voyage  to  the  United  States,  by 
A.  Lkvasski k,  Secretary  to  the  General  during  his  journey, 
2  vols.  12mo.  Translated  by  John  1).  Godxxjt,  M.  D. 

XLIY.    Major   LONG'S    EXPEDITION   to  the 

ROCKY  MOUNTAINS.  2  vols.  Svo.  with  4to  Atlas. 

XLV.     Major    LONG'S    EXPEDITION    to   the 

SOURCES  of  the  MISSISSIPPI,  2  vols.  8vo.  with  Plates. 

XLVI.  NOTIONSof  the  AMERICANS,  by  a  Tra- 
velling Bachelor,  2  vols.  12mo.     By  the  Author  of  the  Spy, 

Pi  (INKERS,   &c. 

XL VII.  The  HISTORY  of  LOUISIANA,  particu- 
larly of  the  Cession  of  that  Colony  to  the  United  States  of 
North  America;  with  an  introductory  Essay  on  the  Constitu- 
tion and  Government  of  the  United  States,  by  M.  de  Marbois, 
Peer  of  France,  translated  from  the  French  by  an  American 
citizen,  in  1  vol.  8vo. 

"From  the  extracts  with  which  we  have  indulged  our  readers,  thaw  will  be 
able  to  form  an  idea  of  the  character  and  spirit  of  M.  de  Marbois's  performance. 
The  outline  which  we  have  drawn,  however,  does  very  scanty  justice  to  the  me- 
nu of  the  whole  work,  which,  we  repeat,  is  in  our  judgment  Use  heat  that  has  re- 
cently appear*  d,  either  at  home  or  abroad,  on  some  of  the  most  important  topics 
of  American  history  and  politics.  If  we  do  not  agree  \\  ith  all  the  author's  opi- 
nions, we  cannot  but  accord  to  him  unqualified  praise  for  his  fairness,  liberality, 
good  judgment,  and  enlightened  t  icwa.  The  volume  v  ill  l>e  a  treasure  among 
the  historical  annals  of  the  country.  We  are  glad  to  know  that  a  translation  of 
it  by  a  competent  hand  is  in  progress  in  Paris,  and  will  speedily  be  published  in 
the 'United  States."— North  American  Rexieie. 


IN  THE  PRESS, 
I.  The  YOUNG  LADIES'  BOOK,  a  Manual  of 
Instructive  Exercises,  Recreations  and  Pursuits.     With  nu- 
merous plates. 

This  is  a  work  recently  published  by  Messrs.  Vizetelly,  Branston  Sc  Co.  Lon- 
don, with  upwards  of  seven  hundred  embellishments,  engraved  in  a  superior 
n  wood.  The  volume  is  a  duodecimo  of  more  than  five  hundred  pages, 
and  sells  in  England  for  one  guinea.  It  is  intended  to  make  the  American  edi- 
tion a  perfect  fac-simile,  or  as  nearly  so  as  practicable  in  this  country,  and  to  af- 
ford it  at  J?  4,  neatly  bound  in  silk,  and  elegantly  gilt.  This  work  cannot  be 
classed  as  Annual,  but  may  be  said  to  be  a  Perennial,  a  suitable  memorial  for  all 
times  and  seasons,  i-  differs  i  nsi  iHjally  from  the  whole  class  of  Literary  Gifts 
usually  presented  to  Young  Ladies,  being  a  complete  manual  for  all  those  ele- 
gant pursuits  which  grace  the  person  and  adorn  the  mind.  The  London  nub- 
ushers  state  that  the  various  subjects  of  which  Uie  volume  is  composed,  have 
been  confined  to  proficients  in  their  several  departments,  and  the  engravings 
have  been  executed  in  the  best  style  of  the  English  artists. 


8  Valuable  TPorks,  fye. 

II.  CHEMISTRY  APPLIED  to  the  ARTS,  on 

the  basis  of  Gray's  Operative  Chemist.  In  8vo.  with  nu- 
merous plates. 

III.  The  PRINCIPLES  and  PRACTICE  of 
,  MEDICINE,  by  Samuel  Jacksox,  M.  D. 

IV.  EXAMINATION  of  MEDICAL  DOC- 
TRINES and  SYSTEMS  of  NOSOLOGY,  preceded  by  PRO- 
POSITIONS containing-  the  SUBSTANCE  of  PHYSIOLOGI- 
CAL MEDICINE,  by  F.  J.  V.  BnorssAis,  Officer  of  the 
Royal  order  of  the  Leg-ion  of  Honour;  Chief  Physician  and 
First  Professor  in  the  Military  Hospital  for  Instruction  at  Pa- 
ris, &c.  &c.  &c.  Third  edition.  Translated  from  the  French, 
by  Isaac  Hats,  M.  D.  and  R.  E.  Griffith,  M.  D. 

V.  BECLARD'S  GENERAL  ANATOMY,  in  1 

vol.  8vo. 

VI.  FARRADAY'S  CHEMICAL  MANIPULA- 
TION, first  American,  from  the  second  London  edition. 

VII.  THOMPSON  on  INFLAMMATION,  second 

American,  from  the  second  London  edition. 

VIII.  WILLIAMS  on  DISEASE  of  the  LUNGS. 

IX.  ARNOTT'S  ELEMENTS  of  PHYSICS,  or 
NATURAL  PHILOSOPHY,  GENERAL  and  MEDICAL,  ex- 
plained independently  of  TECHNICAL  MATHEMATICS— 
Second  volume. 

X.  A  TREATISE  ON  FEVER.  By  Southwood 
Smith,  M.  D.  Physician  to  the  London  Fever  Hospital. 

a  For  simplicity  of  arrangement?  perspicuity  of  view,  power  of  argument 
and  practical  deduction,  this  Treatise  on  Fever  stands  without  competition,  at 
the  head  of  all  that  has  been  written  on  this  abstruse  disease."— Westminster 
Review,  Jan. 

"  There  is  no  man  in  actual  practice  in  this  metropolis,  who  should  not  pos- 
sess himself  of  Dr.  Smith's  work."—  London  Medical  and  SurgicalJournal,  Feb. 

"  While  the  study  of  this  work  must  be  a  matter  of  duty  to  the  members  of  the 
medical  profession,  the  general  reader  will  find  it  perfectly  intelligible,  and  of 
great  practical  utility."— Monthly  Repository,  March. 

"  With  a  mind  so  framed  to  accurate  observation,  and  logical  deduction,  Dr. 
Smith's  delineations  are  peculiarlv  valuable." — Medico-Chir.  Rev.  March. 

XL  The  MUSSULMAN,  bj  R.  R.  Madden,  Esq. 
author  of  Travels  in  Turkey,  Egypt,  Nubia,  and  Palestine,  in 
2  vols. 

►  "  The  portraiture  of  Turkish  life  and  character,  which  this  work  exhibits,  has 
perhaps,  never  been  equalled.  The  account  of  Mohamed  Ali,  the  destruction 
of  jthe  Mamelukes,  the  picture  of  Bedouin  warfare,  the  description  of  the  Der- 
vish, and  of  the  Arabian  Astrologer,  are  indeed  among  the  most  splendid  deli- 
neations ever  introduced  into  the  pages  of  fiction."— Sun. 

XII.  The  ARMENIANS,  a  Tale  of  Constantino- 
ple, by  J.  Macfarland,  in  2  vols. 

"  The  author  will  appreciate  our  respect  for  his  talents,  when  we  say  that  he 
has  done  more  than  any  other  man  to  complete  the  picture  of  the  East,  dashed 
off  by  the  bold  pencil  of  the  author  of  Anastasius."— Edin.  Lit.  Journ. 

XIII.  JOURNAL  of  the  HEART,  edited  by  the 
Authoress  of  Flirtation. 

"  This  is  a  most  charming  and  feminine  volume,  one  delightful  for  a 


to  read,  and  for  a  woman  to  have  w  ritten;  elegant  language,  kind  and  gentle 
thoughts,  a  sweet  and  serious  tone  of  religious  feeling  run  through  every  page, 
and  any  extract  must  do  very  scanty  justice  to  the  merit  of  the  whole.  ****** 
We  most  cordially  recommend  this  Journal  of  the  Heart,  though  we  are  unable 
to  do  it  justice  by  any  selection  of  its  beauties,  which  are  too  ultimately  inter- 
woven to  admit  of  separation."— Literary  Gazette. 


Phi  "lay,  1830. 

Just  Published,  by  Carey  <Sf  Lea, 
And  sold  in  Philadelphia  by  E  L.  Carey  $  A.  Hart;  in  NVw-York 
5y  a  .  '  arviti}  iii  EfoMon  by  0/,'#r  «V  II,ndu—m  Charleston 

by  Ur.  II  Berrett— in  New-Orleans  by  H'.  M'Kean;  by  the  principal 
book-  >n» 

AND  IN  LONDON,  BY  JOHN  MILLER,  ST.  JAMES'3  STREET. 

VOLUMES  III. 

CONTAINING  ABOUT    1500  ARTICLE, 

(2t»  be  continued  at  intervals  of  three  months,) 

OF  THE 

ENCYCLOPAEDIA  AMERICANA: 

A 

POPULAR  DICTIONARY 

OF 

ARTS,  SCIENCES,  LITERATURE.  HISTORY,  AND  POLITICS, 

BROUGHT  DOWN  TO  THE  rr.F«EVT  TIME  AND  INCLCDI.NQ  A  C0H0U3 
COLLECTION   OT  ORIGINAL   A.RTICLE3  IX 

AMERICAN  BIOGRAPHY: 

On  the  basis  of  the  Seventh  Edition  of  the  German 

CONVERSATIOXS-LEXICON. 


Edited  by  Dr.  FRANCIS  LIEBER, 
Assisted  by  EDWARD  WIGGLES  WORTH,  Esa. 


To  be  completed  in  twelve  large  volumes,  octavo,  price  to  subscribers,  bound 
in  cloth,  two  dollars  and  a  half  each. 

EACH  VOLUME  WILL  CONTAIN  BETWEEN  GOO  AND  700  PAGES. 


The  Conversation  Lexicon,  of  winch  the  seventh  edition  in 
twelve  volumes  has  lately  been  published  in  Germany,  origin 
ated  about  fifteen  years  since.  It  was  intended  to  supply  a  want 
occasioned  by  the  character  of  the  age,  in  which  the  sciences, 
arts,  trades,  and  the  various  forms  of  knowledge  and  of  active 
life,  had  become  so  much  extended  and  diversified,  that  no  in- 
dividual engaged  in  business  could  become  well  acquainted 
with  all  subjects  of  general  interest ;  white  the  wide  diffusion 
of  information  rendered  6uch  knowledge  essential  to  the  charac- 
ter of  an  accomplished  man.  This  want,  no  existing  works 
were  adequate  to  supply.  Books  treating  of  particular  branch- 
es, such  as  gazetteers,  &c.  were  too  confined  in  character; 
while  voluminous  Encyclopedias  were  too  learned,  scientific, 


M  EXCYCLOPJEDIA    AMERICANA. 

and  cumbrous,  being  usually  elaborate  treatises,  requiring  much 
study  or  previous  acquaintance  with  the  subject  discussed.  The 
conductors  of  the  Conversation  Lexicon  endeavored  to  select 
from  every  branch  of  knowledge  what  was  necessary  to  a  well- 
informed  mind,  and  to  give  popular  views  of  the  more  abstruse 
branches  of  learning  and  science ;  that  their  readers  might  not 
be  incommoded,  and  deprived  of  pleasure  or  improvement,  by 
ignorance  of  facts  or  expressions  used  in  books  or  conversation. 
Such  a  work  must  obviously  be  of  great  utility  to  every  class  of 
readers.  It  lias  been  found  so  much  so  in  Germany,  that  it 
is  met  with  everywhere,  among  the  learned,  the  lawyers,  the 
military,  artists,  merchants,  mechanics,  and  men  of  all  stations. 
The  reader  may  judge  how  well  it  is  adapted  to  its  object, 
from  the  circumstance,  that  though  it  now  consists  of  twelve 
volumes,  seven  editions,  comprising  about  one  hundred  thou- 
sand copies,  have  been  printed  in  less  than  fifteen  years.  It 
has  been  translated  into  the  Swedish,  Danish  and  Dutch  lan- 
guages, and  a  French  translation  is  now  preparing  in  Paris. 

A  great  advantage  of  this  work  is  its  liberal  and  impartial 
character ;  and  there  can  be  no  doubt  that  a  book  like  the  En- 
cyclopedia Americana  will  be  found  peculiarly  useful  in  this 
country,  where  the  wide  diffusion  of  the  blessings  of  education, 
and  the  constant  intercourse  of  all  classes,  create  a  great  de- 
mand for  general  information. 

In  the  preparation  of  the  work  thus  far,  the  Editors  have 
been  aided  by  many  gentlemen  of  distinguished  ability ;  and  for 
the  continuation,  no  efforts  shall  be  spared  to  secure  the  aid  of 
all  who  can,  in  any  way,  contribute  to  render  it  worthy  of 
patronage. 

The  American  Biography,  which  is  very  extensive,  will  be 
furnished  by  Mr.  Walsh,  who  has  long  paid  particular  atten- 
tion to  that  branch  of  our  literature,  and  from  materials  in  the 
collection  of  which  he  has  been  engaged  for  some  years.  For 
obvious  reasons,  the  notices  of  distinguished  Americans  will  be 
confined  to  deceased  individuals:  the  European  biography  con- 
tains notices  of  all  distinguished  living  characters,  as  well  as 
those  of  past  times. 

The  articles  on  Zoology  have  been  written  expressly  for  the 
present  edition  by  Dr.  John  D.  Godman  ;  those  on  Chemistry 
and  Mineralogy,  by  a  gentleman  deeply  versed  in  those  de- 
partments of  science. 

In  relation  to  the  Fine  Arts,  the  work  will  be  exceedingly 
rich.  Great  attention  was  given  to  this  in  the  German  work, 
and  the  Editors  have  been  .anxious  to  render  it,  by  the  necessary 
additions,  as  perfect  as  possible. 

To  gentlemen  of  the  Bar,  the  work  will  be  peculiarly  vahia-> 
ble,  as  in  cases  where  legal  subjects  are  treated,  an  account  is 


ENCYCLOPAEDIA    AMERICANA.  *S 

given  of  the  provisions  of  American,  English,  French,  Prussian, 
Austrian,  and  Civil  I 

The  Publishers  believe  it  will  be  admitted,  that  this  work  is 
one  of  the  cheapest  ever  published  in  this  country.  They  have 
been  desirous  to  render  it  worthy  of  a  place  in  the  best  libraries, 
while  at  the  same  time  they  have  fixed  the  price  so  low  as  to 
put  it  within  the  reach  of  all  who  read. 

Those  who  can.  by  any  honest  model  of  economy,  reserve  the  sum  of  two 
dollars  and  fifty  cent*  quarterly,  from  their  family  expenses,  may  pay  for  this 
work  as  fasl  as  it  is  published  ;  and  wo  confidently  believe  that  they  will  tind 
at  the  end  thai  they  never  purchased  so  much  general,  practical,  useful  infor- 
mation at  so  cheap  a  rate.—  Journal  of  Education. 

If  the  encouragem  :nt  to  the  publishers  should  correspond  with  the  testimony 
in  favor  of  their  enterprise,  and  the  beautiful  and  faithful  style  of  its  execu- 
tion, the  hazard  of  the  undertaking,  bold  as  it  was,  will  be  well  compensated  ; 
and  our  libraries  will  !>..•  enriched  by  the  most  generally  useful  encyclopedic 
dictionary  that  has  been  offered  to  the  readers  of  the  English  Language.  Full 
enough  for  the  ir< •  1 1  ial  scholar,  and  plain  enough  for  every  capacity,  it  is  far 
more  convenient,  in  every  view  and  form,  than  its  more  expensive  and  ponder- 
American  Fur, 
high  reputation  of  the  contributors  to  this  work,  will  not  fail  to  insure 
it  a  favorable  reception,  and  its  own  merits  will  do  the  rest. — Silliman's  Joum. 

Tin:  work  will  be  a  valuable  possession  to  eveiy  family  or  individual  that 
can  afford  to  purchase  it;  and  we  take  pleasure,  therefore,  in  extending  the 
knowledge  of  its  merits. — JVbrto  ial  Intelligencer. 

The  Encyclopedia  Am  Tirana  is  a  prodigious  improvement  upon  all  that 
has  gone  before  it ;  a  thing  for  our  country,  as  well  as  the  country  that  gave 
it  birth,  to  be  proud  of;  an  inexhaustible  treasury  of  useful,  pleasant  and  fa- 
miliar learning  on  every  possible  subject,  so  arranged  as  to  be  speedily  and 
referred  to  on  cm  rgency,  as  well  as  on  deliberate  inquiry;  and  better 
still,  adapted  to  the  understanding,  and  put  within  the  reach  of  the  multitude. 
*  *  *  The  Ensyclopac  lia  Americana  is  a  work  without  which  no  library 
worthy  of  the  name  can  hereafter  be  made  up. — Yankee. 

The  copious  information  which,  if  a  just  idea  of  the  whole  may  be  formed 
from  the  first  volume,  tins  work  affords  on  American  subjects,  fully  justifies 
its  title  of  an  American  Dictionary;  while  at  the  same  time  the  extent,  varie- 
ty, and  felicitous  disposition  of  its  topics,  make  it  the  most  convenient  and 
satisfactory  Encyclopaedia  that  we  have  ever  seen. — NationalJoumal. 

If  the  succeeding  volumes  shall  equal  in  merit  the  one  before  us,  we  may 
confidently  anticipate  for  the  work  a  reputation  and  usefulness  which  ought 
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Gazette. 

The  variety  of  topics  is  of  course  vast,  and  they  are  treated  in  a  manner 
which  is  at  once  so  full  of  information  and  so  interesting,  that  the  work,  in 
stead  of  being  merely  referred  to,  might  be  regularly  perused  with  as  much 
pleasure  as  profit. — Baltimore  American. 

We  view  it  as  a  publication  worthy  of  the  age  and  of  the  country,  and  caiw 
not  but  believe  the  discrimination  of  our  countryman  will  sustain  the  publish- 
ers, and  well  reward  them  for  this  contribution  to  American  Literature.— 
Baltimore  Patriot. 

We  cannot  doubt  that  the  succeeding  volumes  will  equal  the  first,  and  we 
hence  warmly  recomm  n  I  the  work  to  the  patronage  of  the  public,  as  beins  by 
far  the  best  work  of  th  •  kind  over  offered  for  sale  in  this  country. —  U.  S.  Oaz. 

It  reflects  the  greatest  credit  on  those  who  have  been  concerned  in  its  pro- 
duction, and  promises,  in  a  variety  of  respects,  to  be  the  best  as  well  as  the 
most  compendious  dictionary  of  the  arts,  sciences,  history,  politics,  biography, 
&c.  which  has  yet  been  compiled.  The  style  of  the  portion  we  have  rr?ad 
is  terse  and  perspicuous;  and  it  is  really  curious  how  so  much  scientific  and 
other  information  could  nave  been  so  satisfactorily  communicated  in  such  brief 
limits.— JV.  Y.  Evening  Pot. 

A  compendious  library,  and  invaluable  book  of  reference.— JV.  Y.  American 


4  ENCYCLOPAEDIA    AMERICANA. 

This  cannot  but  prove  a  valuable  addition  to  the  literature  of  the  age.— Met 
Advertiser. 

The  appearance  of  the  first  volume  of  this  valuable  work  in  this  country,  is 
an  event  not  less  creditable  to  its  enterprising  publishers,  than  it  is  likely  to 
prove  lastingly  beneficial  to  the  public.  When  completed,  according  to  the 
model  presented  by  the  first  volume,  it  will  deserve  to  be  regarded  as  the  spirit 
of  all  the  best  Encyclopaedias,  since  it  comprises  whatever  is  really  desirable 
and  necessary  in  them,  and  in  addition,  a  large  proportion  of  articles  entirely 
original,  or  expressly  written  for  its  pages.  This  is  the  condition  of  all  the 
articles  of  American  Biography,  by  Mr.  Walsh ;  those  on  Zoology,  by  Dr.  God- 
man  ;  and  those  on  Mineralogy  and  Chemistry,  by  a  gentleman  of  Boston, 
distinguished  for  his  successful  devotion  to  those  studies.  The  work  abounds 
with  interesting  and  useful  matter,  presented  in  a  condensed  and  perspicuous 
style;  nor  is  it  one  of  its  least  commendations  that  it  is  to  he  comprised  in 
twelve  octavo  volumes,  which  may  be  placed  on  an  office  table,  or  occupy  a 
shelf  in  the  parlor,  ever  ready  for  immediate  reference,  instead  of  requiring 
almost  a  room  to  itself,  like  its  ponderous  predecessors,  the  Britannica,  Edin- 
burgensis,  &c. 

The  vast  circulation  this  work  has  had  in  Europe,  where  it  has  already  been 
reprinted  in  four  or  five  languages,  not  to  speak  of  the  numerous  German  edi- 
tions, of  which  seven  have  been  published,  speaks  loudly  in  favor  of  its  in- 
trinsic merit,  without  which  such  a  celebrity  could  never  have  been  attained. 
To  every  iudn  engaged  in  public  business,  who  needs  a  correct  and  ample  book 
of  reference  on  various  topics  of  science  and  letters,  the  Encyclopaedia  Ameri- 
cana will  be  almost  invaluable,  lo  individuals  obliged  to  goto  situations 
where  books  are  neither  numerous  nor  easily  procured,  the  rich  contents  of 
these  twelve  volumes  will  prove  a  mine  which  will  amply  repay  its  purchaser, 
and  be  with  difficulty  exhausted,  and  we  recommend  it  to  their  patronage  in 
the  full  conviction  of  its  worth.  Indeed  it  is  difficult  to  say  to  what  class  of 
readers  such  a  book  would  not  prove  useful,  nay,  almost  indispensable,  since 
it  combines  a  great  amount  of  valuable  matter  in  small  compass,  and  at  mode- 
rate expense,  and  is  in  every  respect  well  suited  to  augment  the  readers  stock 
of  ideas,  and  powers  of  conversation,  without  severely  taxing  time  or  fatiguing 
attention.  These,  at  least,  are  our  conclusions  after  a  clo|f  and  candid  ex- 
amination of  the  first  volume. — Am.  Daily  advertiser. 

We  have  seen  and  carefully  examined  the  first  volume  of  the  Encyclopaedia 
Americana,  just  published  by  Carey.  Lea  and  Carey,  and  think  our  readers  may 
be  congratulated  upon  the  opportunity  of  making  such  a  valuable  accession  to 
their  libraries.— Aurora. 

The  department  of  American  Biography,  a  subject  of  which  it  should  be 
disgraceful  to  be  ignorant,  to  the  degree  that  many  are,  is,  in  this  work,  a 
prominent  feature,  and  has  received  the  attention  of  one  of  the  most  indefati- 
gable writers  in  this  department  of  literature,  which  the  present  age  can  fur- 
nish.— Boston  Courier. 

According  to  the  plan  of  Dr.  Lieber,  a  desideratum  will  be  supplied ;  the  sub- 
stance of  contemporary  knowledge  will  be  brought  within  a  small  compass; — 
and  the  character  and  uses  of  a  manual  will  be  imparted  to  a  kind  of  publica- 
tion heretofore  reserved,  on  strong  shelves,  for  occasional  reference.  By  those 
who  understand  the  German  language,  the  Conversation  Lexicon  is.  consulted 
ten  times  for  one  application  to  any  English  Encyclopaedia. — National  Oaz. 

The  volume  now  published  is  not  only  highly  honorable  to  the  taste,  ability 
and  industry  of  its  editors  and  publishers,  but  furnishes  a  proud  sample  of  the 
accuracy  and  elegance,  with  which  the  most  elaborate  and  important  literary 
enterprises  may  now  be  accomplished  in  our  country.  Of  the  manner  in  which 
the  editors  have  thus  far  completed  their  task,  it  is  impossible,  in  the  course  of 
a  brief  newspaper  article,  to  speak  with  adequate  justice.— Boston  Bulletin. 

We  have  looked  at  the  contents,  generally,  of  the  second  volume  of  this 
work,  and  think  it  merits  the  encomiums  which  have  been  bestowed  on  it  in 
the  northern  papers.  It  continues  to  be  particularly  rich  in  the  departments 
of  Biography  and  Natural  History.  When  we  look  at  the  large  mass  of  mis- 
cellaneous knowledge  sprod  before  the  reader,  in  a  form  which  has  never  been 
equalled  for  its  condensation,  and  conveyed  in  a  style  that  cannot  be  surpassed 
for  propriety  and  perspicuity,  we  cannot  but  think  that  the  American  Ency- 
clopaedia deserves  a  place  >n*every  collection,  in  which  works  of  reference  form 
a  portion."— Southern  Patriot. 


RATIONAL  EXPOSITION 


THE   PHYSICAL   SIGNS 


OF    THE 


DISEASES 


E  LUNGS  AND  PLEURA ; 


ILLUSTRA^ 


^THE[R  PATHOLOGY,  AND  FACILITATING 
//^I^D^^OSIS. 


By  CHARLES  J.  B.  WILLIAMS,  M.  D. 


h 


CL 


PHILADELPHIA: 

CAREY  AND  LEA-CHESNUT  STREET. 

1830. 


E.  St  G.  Merriam,  Printers,  Brookfield,  Mass. 


b 


TO 


SIR  HENRY  HALFORD,  Bart. 


PRESIDENT    OF    THE    ROYAL    COLLEGE    OF    PHYSICIANS,    PHYSICIAN 
TO    THE    KING,    &C.  &C. 


My  dear  Sir, 

To  you,  the  learned  and  justly  distinguished 
head  of  our  profession,  I  dedicate  this  work. 
Were  the  illustrious  inventor  of  Auscultation 
living,  duty  and  inclination  would  have  guided 
my  pen  to  inscribe  his  name  on  this  page.  He 
is  not ;  and  when  I  turn  to  you  for  the  sanction 
of  this  little  production,  I  feel,  that  whatever 
slight  merits  it  may  p  ossess,  will  meet  with  the 
approbation  of  an  equally  enlightened  mind,  and 
the  urbane  protection  of  a  candid  authority. 

With  every  sentiment  of  respect  and  esteem, 
I  am,  my  dear  Sir,  your  very  faithful 
and  obliged  Servant, 

C.  J.  B.  WILLIAMS. 

London,  May  21, 1828. 


X 


PREFACE. 


A  discovery,  a  new  doctrine,  or  an  innovation  of 
any  kind,  produces  a  curious  agitation  in  the  public 
mind,  which,  in  a  remarkable  manner,  illustrates  the 
paradoxical  and  heterogeneous  composition  of  human 
character.  Tossed  to  and  fro  by  the  exertions  of  its 
opponents,  and  of  its  scarcely  less  opposing  ultra-par- 
tisans, it  resembles  a  pendulum  ;  and  vibrating  irregu- 
larly between  many  disturbing  forces,  it  is  driven  out 
of  the  real  sphere  of  its  importance,  and  from  that  true 
point  of  utility  to  which  its  intrinsic  weight  and  worth 
would  cause  it  to  gravitate. 

More  particularly  has  this  happened  in  medicine, 
which,  having  few  standard  or  fixed  points  to  steady 
it,  has  been  ever  too  much  at  the  mercy  of  contending 
opinions.  The  localization  of  diseases  is  a  characte- 
ristic doctrine  of  the  present  day;  and  most  assuredly 
such  a  system  would  be  the  most  scientific,  that  could 
trace  the  multifarious  forms  of  disease  to  a  few  simple 
primary  lesions  of  tissue,  or  well  defined  alterations  of 
function  ;  and  that  plan  of   practice    the  most  eflica- 


VI  PREFACE. 

cious  that  could  concentrate  its  efforts  against  the  very 
root  of  evil,  and  stop  at  its  very  spring-source  the  cur- 
rent of  disorder.  But  we  are  far  from  having  attained 
such  a  perfection  ;  and  let  caution,  therefore,  remind 
us,  that  hastily  to  follow  a  light,  which,  however  pure 
and  real,  is  yet  at  distance  too  remote  to  shed  its 
rays  upon  our  paths,  is  scarcely  less  dangerous,  than 
to  chase  an  empty  ignis  fatuus  ;  that  to  grasp  at  an 
object,  however  perfect  and  substantial,  so  far  beyond 
our  present  reach,  is  not  less  futile  than  to  catch  at  an 
illusory  shadow. 

The  local  study  of  diseases  must  not,  therefore,  re- 
move our  attention  from  their  general  phenomena  ;  our 
examination  of  their  physical  nature  must  not  exclude 
the  consideration  of  many  constitutional  effects,  that  by 
reaction  may  often  become  converted  into  causes  ;  and 
still  less  should  physical  signs  of  doubtful  import  make 
us  neglect  obvious  disorder  of  the  system. 

But,  thus  limited,  the  local  study  of  diseases  is  more 
advantageous  than  the  knowledge  of  their  general 
forms ;  an  examination  of  their  physical  signs,  when 
possible,  more  useful  than  the  perplexing  consideration 
of  a  host  of  uncertain  and  fallacious  constitutional 
symptoms  ;  and  when  physical  signs  are  wanting,  or 
beyond  the  sphere  of  our  observation,  those  constitu- 
tional ones  are  our  best  guides,  which  most  nearly  de- 
pend on  the  physical  and  unchangeable  character  of 
the  disease.  For  the  local  study  of  a  disease  acquaints 
us  with  its  proximate  and  essential  cause,  and  this 
knowledge  suggests  means  for  its  removal  ;  and  by  a 
study  of  its  physical  signs,  and  of  those  general  ones 
most  allied  to  them,  we  obtain  the  most  certain  me- 
thod of  discovering  its  existence,  and  of  distinguishing 
its  character.  • 


PREFACE.  VII 

Further  than  this,  I  shall  not  expatiate  on  the  ad- 
vantages or  disadvantages  of  the  new  methods  of  diag- 
nosis of  diseases  of  the  chest.  They  are  now  too  well 
understood  and  appreciated  to  be  in  danger  of  yielding 
to  the  opposition  of  prejudice,  or  of  falling  into  obli- 
vion through  neglect.  Too  many  ears  have  been  open- 
ed to  the  language  of  disease,  to  suffer  its  warnings  to 
be  lost  without  a  listener  ;  too  many  minds  are  con- 
vinced of  the  truth  of  its  admonitions,  to  permit  them 
to  pass,  as  hitherto,  unheeded.  Those  who  are  dis- 
posed to  study  the  signs  of  auscultation  and  percus- 
sion, will  soon  find  in  that  study  the  proofs  of  their 
merit  and  importance  ;  those  who  will  not  examine 
them,  are  not  likely  to  be  more  moved  by  any  com- 
mendations that  I  could  bestow,  than  by  those  that  have 
already  been  written  in  their  favour. 

The  "  Traite  de  V  Auscultation  Mediate,"  and  the 
perfect  translation  of  Dr.  Forbes,  are  at  length,  gene- 
rally appreciated,  even  in  this  country,  slow  to  award  its 
meed  of  praise.  The  homage  paid  to  the  talents  of  the 
author,  gives  me  a  gratification  that  almost  seems  per- 
sonal ;  and  I  doubt  not  that  this  feeling  is  shared  by 
others  of  his  pupils,  in  whom  his  urbane  and  amiable 
deportment  created  a  sincere  regard  for  the  man,  as 
his  great  mental  abilities  excited  our  respect.  His 
great  talents  are  known  to  the  public  through  the 
medium  of  his  writing  ;  but  those  who  attended  his 
clinique  can  alone  appreciate  the  wonderful  acute- 
ness  of  perception,  and  faculty  for  observation,  that 
enabled  him  to  carry  his  discovery  to  the  degree  of 
perfection  in  which  he  left  it;  and  they,  above  all,  wit- 
nessed, felt,  and  profited  by  the  solicitous  interest  which 
he  showed  to  make  others  partake  of  its  inestimable 
advantages.     They  felt  in  his  death  the  loss  of  a  friend  ; 


Vlll  PREFACE. 

as  science  had  to  deplore  the  loss  of  his  talents  ;  he 
has  wrought  a  good  work  for  both  ;  the  feeling  shall 
last  while  they  last ;  science  has  recorded  his  name  on 
her  tablets  for  ever  : — 

"  Ilium  aget  penna  metuente  solvi 

"  Fama  superstes." 

Let  me  say  a  few  words  on  the  objects  and  plan  of 
the  present  work. 

I  have  ever  found  in  practice,  and  it  is  perfectly  con- 
formable to  reason,  that  the  easiest  and  most  agreeable 
way  to  study  physical  signs,  and  to  attain  the  surest 
criterion  of  their  value  and  importance,  is  by  consider- 
ing how  they  are  caused,  or  what  are  the  relations  in 
which  they  stand  to  the  physiological  and  pathological 
states  that  produce  them.  Attempts  to  discover  the 
rationale  of  the  general  symptoms  of  disease  have  been 
as  unsuccessful  as  our  knowledge  of  the  functions  or 
properties,  on  which  they  depend,  is  scanty  and  imper- 
fect ;  and  inquiries  of  this  kind  have  been  proportion- 
ately unsatisfactory  and  unprofitable.  But  physical 
signs  stand  on  the  broad  and  intelligible  basis  of  phy- 
sical laws,  and  are  as  readily  explained  as  other  simple 
phenomena,  illustrated  by  natural  philosophy.  It  has 
been  my  endeavour  to  exhibit  them,  as  far  as  possible, 
in  this  intelligible  view  ;  to  show  the  mechanism  by 
which  the  signs  are  produced,  and  the  manner  in  which, 
according  to  fixed  laws,  they  result  as  phenomena ;  to 
make  a  knowledge  of  the  pathology  predicate  the  signs, 
and  a  knowledge  of  the  signs  indicate  the  pathology  ; 
and  by  thus  familiarising  the  mind  with  their  principles, 
to  enable  it  to  understand  the  multifarious  forms  which, 
by  combination,  these  signs  may  assume,  and  to  judge 


PREFACE.  IX 

of  the  corresponding  physical  changes  that  modify  or 
produce   them. 

I  have  not  refrained,  when  the  subject  seemed  to  re- 
quire it,  or  where  1  had  any  new  view  to  offer,  from 
entering  on  some  questions  of  general  pathology.  I 
am  not  clear  that  I  have  been  judicious  in  so  doing  ; 
for  the.  slight  views,  that  I  have  given  of  these  ques- 
tions, may  be  deemed  too  superficial  and  unsupported 
to  be  satisfactory  ;  and  had  I  developed  them  in  tho 
manner  in  which  I  am  prepared  to  do,  it  would  have 
completely  changed  the  size  and  nature  of  the  work. 
These  opinions,  as  well  as  my  acquaintance  with  the 
physical  signs,  are  the  result  of  some  extent  of  study 
and  observation,  prosecuted  chiefly  in  the  wards  of  La 
Charite,  where  Laennec  taught,  and  Andral  prosecuted 
his  studies.  Most  of  the  facts  which  I  have  described 
have  appeared  in  the  works  of  these  illustrious  men  ; 
and  wherever  my  experience  has  not  enabled  me  to 
give  the  same  as.  the  result  of  my  own  observation,  I 
have  referred  to  their  competent  authority.  Where, 
in  point  of  fact,  or  opinion,  I  have  differed  from  them 
or  from  others,  I  would  wish  my  dissent  to  be  viewed 
rather  as  a  question  to  be  answered  by  others,  than  as 
in  itself  superseding  former  observations  or  opinions. 

I  have  divided  this  work  into  two  parts  :  the  first 
contains  an  exposition  of  the  general  physical  signs  of 
a  healthy  and  diseased  state  and  action  of  the  thoracic 
viscera,  to  which  I  have  prefixed  a  chapter  on  the 
properties,  &c,  of  sound  ;  the  second  comprehends 
the  pathological  history,  and  physical  signs,  of  the 
principal  diseases  of  the  lungs  and  pleura.  I  have  in- 
serted at  the  end  of  the  volume  some  tabular  views  of 
the  physical  signs,  &c.  illustrated  by  a  plate,  showing 
the  situation  of  the  regions  of  the  chest.  These  are 
2 


X  PREFACE. 

to  be  considered  more  as  tables  of  reference  to  assist 
the  memory,  than  as  containing  any  exact  or  adequate 
expositions  of  their  subjects.  The  diagram  of  the  ste- 
thoscope, and  the  accompanying  explanation  of  the 
best  principles  of  its  construction,  I  have  thought 
worth  adding,  as  workmen  have  hitherto  had  little  but 
fancy  to  guide  them. 


CONTENTS. 


Paces. 
PARTI.    Chap.  I.  13—25 

On  the  Physical  Signs  of  Disease,  13 — 15  ;  Applicability 
of  Hearing  the   Study  of  Disease,    15,    16  ;    Properties  of 
Sound  ;  Nature  of  Vibrations  ;  Differences  of  Sounds  ;  Har- 
monic and  Discordant   Vibrations;  Conduction   of  Sound  ; 
Sources  of  Sounds  ;  Reflection  of  Sound,  16 — 25. 

Chap.  II. — On  the  Physical  Signs  of  the  State  and  Action 
cfthe  Thoracic  Viscera  26 — 70 

Utility  of  Physical  Signs,  26—28.  Sect.  I.— On  Percus- 
sion. Causes  of  Pectoral  Resonance,  29  ;  Causes  of  its  Mo- 
difications, 30;  Method  of  Percussion,  31 — 33;  Mediate 
Percussion,  33,  34.  Sect.  II. — On  Auscultation,  Auscul- 
tation of  Respiration  ;  Tracheal,  Bronchial,  and  Vesicular 
Respiration,  35 — 37 ;  Varieties,  Puerile  Respiration,  &c., 
37 — 41  ;  Effects  of  Disease,  42  ;  Cavernous  Respiration,  43 ; 
Rhonchi,  43  ;  Sibilant,  44  ;  Sonorous,  Dry  Mucous,  45  ;  Mu- 
cous, 46—48  ;  Crepitant,  48  ,  49  ;  Sounds  of  the  Cough, 
50,  51  ;  Sounds  of  the  Voice,  Laryngophony,  Broncophony, 
Pectoriloquy,  51 — 57. 

Sect.  III. — Auscultation  of  the  Heart.  Nature  and  Order 
of  the  Sounds  of  Pulsation,  57 — 59  ;  Effects  of  Disease, 
CO — 62  ;  Method  of  Auscultation,  Immediate  Auscultation, 
63;  the  Stethoscope,  64—67;  Use  of  the  Stethoscope,  67 
—70. 

PART  II. — On  the  Physical  Signs  of  Diseases  or  the 
Lungs  and  Pleura. 

Chap.  I.— Diseases  of  the  Air  Tubes  -  -  72—91 

Sect.  I. — Acute  Bronchitis,  Pathology  and  Signs,  72 — 77  ; 
Chronic  Bronchitis  ;  Signs ;  Distinction  from  Phthisis  ;  Dila- 
tation of  the  Bronchi,  &c.  77 — S2.  Sect.  II. — Pituitary 
Catarrh,  82— 84.  Sect.  III.— Dry  Catarrh,  84— 86.  Sect. 
IV. — Pertussis,  86  ;  Croup,  87  ;  Ulcers  and  Tumours  of  the 
Bronchi,  88   Sect.  V. —  Spasmodic  Asthma,  89 — 91. 

Chap.  II. — Diseases  affecting  the  Tissue  of  the  Lungs  92—115 

Sect.  I. — Peripneumony,  1st  stage  ;  Pathology,  Causes 
of  Rhonchus  Crepitans,  92 — 94  ;  2d  stage,  Pathology,  Bron- 
chial Respiration,  &c.  94 — 96  ;  3d  stage,  96  ;  Abscess  and 
Gangrene,  97  ;  Progress  of  the  Inflammation,  98  ;  Retro- 
gression, 99;  Partial  Peripneumony,  101  ;  Signs  of  Percui- 


xii  CONTENTS. 

sion,  102  ;  Sputa,  102—105.     Sect.  II.— Emphysema  of  the  Pages 

Lungs,  Pathological  Causes,  105—107  ;  Signs,  108  ;  Inter- 
lobular Emphysema,  109.  Sect.  III.— CEdema  of  the  Lungs  ; 
Pathology  and  Signs,  110—112.  Sect.  IV.— Pulmonary  Apo- 
plexy ;  Signs;  Haemoptoe,  &c.  112 — 115. 

Chap.  III. — Diseases  of  the  Pleura    -  116 — 158 

Sect.  I. — Pleurisy,  Physical  Signs ;  JEgophony,  and  its 
Causes,  &c.  116—123;  Latent  State  of  Pleurisy,  123,  124; 
Retrogression  of  Pleurisy,  125  Double  Pleurisy,  126 ; 
Terminations  of  Pleurisy,  127 ;  Effects  of  Inflammation  on 
Tissues,  127—130  ;  Adhesions,  130,  131  ;  Hemorrhagic 
Pleurisy,  Contraction  of  the  Chest,  132 — 134  ;  Pneumothorax 
of  Necessity,  135  ;  Chronic  Pleurisy  ;  Nature  of  Empy- 
ema ;  Signs;  136 — 138.  Sect.  II. — Pleuropneumonia,  Pa- 
thology, 139  ;  Signs,  140—142.  Sect.  III.— Hydro  thorax  ; 
Uncertainty  of  General  Signs,  142  ;  Physical  Signs.  143, 
Sect.  IV. — Hcemothorax,  144.  Sect.  V.  Pneumothorax; 
Pathological  Nature,  145  Physical  Signs,  146 ;  with  Li- 
quid Effusion,  147:  Succession  of  the  Chest,  148;  Causes  of 
Tinnitus  Metallicus,  149—158. 

Chap.  IV.—  Phthisis  Pulmonalis  158—19* 

Sect.  I. — Pathology,  Granulation,  Indurations,  159. 
Crude  Tubercles,  160;  Softening  and  Evacuation,  161;  Ca- 
vities, 161 — 163  ;  Inquiry  into  the  Pathology  of  Phthisis,  and 
Nature  of  Tubercle,  163—171;  Causes  of  Tubercles,  172; 
Inefhcacy  of  Medicine,  173 — 175.  Sect.  II. — Physical 
Signs.  Signs  of  Crude  Tubercles  and  Indurations,  175 — 179  ; 
Signs  of  Softening  and  Evacuation,  Signs  og  Cavities,    179  - 

Cavernous    Rhonchus,    180  ;  Cavernous   Respiration,    181 

183  ;  Pectoriloquy,  how  produced,  various  kinds,  183-188  ; 
Distinction  between  Cavities  and  dilated  Bronchi,  189  ;  Com- 
plications, 190  ;  Perforation  of  the  Pleura,  191  ;  Sputa  in  the 
last  stage,  191 — 192  ;  Cicatrization  of  Cavaties,  192 — 193  ■ 
Chances  of  Cure,  193 — 194  ;  Melanosis,  Hydatids,  &c,  194 — 
195. 

EPPLANATION  OF  THE  PLATES. 
Pl.I.     Construction  of  the  Stethoscope   196 — 199. 
Tabular  View  of  the  Regions,  &c.  200 — 201. 
Pl.  II.  Additional  Observations  on  Mediate  Percussion,  202 — 203. 
Tabular  View  of  Physical  Signs,  &c.  204—205. 


PART  I.— CHAP  I. 


ON    THE    PHYSICAL    SIGNS    OF    DISEASE 


By  physical  signs  I  mean  such  as  depend 
on  the  direct  operation  of  known  laws  of  na- 
tural philosophy  on  our  organs  of  sensation. 
As  they  are  produced  by  the  physical  state  or 
condition  of  a  part,  they  become  indications  of 
that  state  or  condition,  as  certain,  as  the  laws, 
of  which  they  are  exemplifications,  are  unerring 
and  sure  :  and  the  physical  state  of  a  part 
of  the  body  may  be  ascertained  with  more  or 
less  certainty,  as  its  physical  signs,  or  relations 
to  these  natural  laws,  are  more  or  less  appreci- 
able by  our  senses. 

The  organs  of  vision,  impressed  by  the  forms 
and  properties  in  relation  to  light,  and  perfected 


14  ON  THE  PHYSICAL  SIGNS  OF  DISEASE, 

by  the  immediate  correction  of  touch,  are,  both 
by  nature  and  habit,  calculated  to  give  us  a 
more  perfect  knowledge  of  external  objects, 
than  can  be  derived  from  the  other  senses. 
But  the  number  of  diseases  that  come  under 
the  cognizance  of  vision  is  very  limited,  as  by 
far  the  greater  part  of  the  body  is  excluded 
from  its  sphere.  Derangements  of  the  surface, 
and  of  the  openings  of  some  of  the  passages  to 
the  interior,  can  alone  be  subjected  to  the  direct 
examination  of  the  eye.  Mediately,  physical 
changes  of  internal  organs  can  be  perceived  by 
sight  only,  when  their  size,  form,  or  position  is 
so  far  altered  as  to  cause  displacement  of  some 
external  part ;  and  the  knowledge  that  such  a 
sign  gives  us,   although  scanty,  is  often  valuble. 

The  sense  of  touch,  or  tact,  will,  in  the  same 
cases,  furnish  us  with  further  knowledge  as  to 
the  form,  substance,  and  constitution  of  a  dis- 
eased part ;  and,  when  perfected  by  experience, 
may  frequently  discover  organic  changes  that 
are  altogether  imperceptible  to  sight. 

The  sense  of  smell  is  more  rarely  qualified 
to  distinguish  disease  ;  as  its  impressions  can 
only  be  conveyed  through  the  medium  of  air, 
probably  in  motion  ;  yet  we  shall  find  that  cases 
are  not  wanting  in  which  this  sense  may  assist 
us  in  diagnosis. 

Sound,  as  it  may  be  both   generated  and  pro- 


ON  THE  PHYSICAL  SIGNS  OF  DISEASE.  15 

pagated  in  every  form  of  matter,  solid,  liquid, 
and  aeriform,  may  be  therefore  considered  a 
mean  of  examination  of  parts  removed  from 
sight  and  tact,  more  promising  as  its  sphere  is 
less  limited.  It  is  requisite,  however,  that  the 
object  of  examination  be  capable  of  producing 
or  transmitting  audible  sound ;  and  that  changes 
in  the  part  produce  corresponding  changes 
in  sound  thus  produced  or  transmitted,  that 
may  be  appreciated  by  the  ear.  The  relations 
of  the  organ  of  hearing  to  the  qualities  of  ex- 
ternal objects,  are,  in  ordinary  life,  much  less 
exercised  than  those  of  tact  and  vision.  Yet 
continual  experience  proves  to  us  that  the  sub- 
stance or  consistence  of  simple  objects  is,  in 
some  measure,  declared  by  the  sound  which 
they  emit  when  struck.  The  sound  of  liquids 
in  contact  with  air  is  familiarly  distinguished 
from  that  of  solids  in  the  same  medium,  and  a 
little  more  attention  discovers  the  varied  sounds 
which  air  in  motion  produces  in  contact  with 
solids  of  different  forms. 

Such  scanty  knowledge  of  the  relations  of 
sound  suffices  for  the  common  purposes  of  life  : 
to  study  them  more  closely,  with  a  view  to  dis- 
cover the  nature  of  objects,  were  a  work  of  su- 
pererogation whilst  sight  and  tact  are  capable  of 
giving  us  much  more  perfect  and  certain  in- 
formation.   But  an  individual  deprived  of  sight 


16  ON    THE  PROPERTIES  OF  SOUND. 

substitutes  a  perfection  of  tact  and  of  hearing 
and  distinguishing  sounds,  which,  in  a  great 
degree,  compensates  for  his  want  of  vision.  So 
likewise  may  we,  with  equal  advantage,  so  per- 
fect our  sense  of  hearing,  as  to  make  its  indi- 
cations available  to  instruct  us  of  objects  be- 
yond the  sphere  of  tact  and  vision.  Now  such 
perfection  must  in  great  measure  depend  on  the 
practice  of  each  individual,  as  a  knowledge  of 
simple  sensations  cannot  be  transferred  by  de- 
scription ;  but  the  study  may  be  much  assisted 
and  simplified  by  a  general  knowledge  of  the 
chief  laws  according  to  which  sound  is  pro- 
duced and  propagated.  Unfortunately  acous- 
tics is  a  branch  of  natural  philosophy  that  has 
been  neglected  to  an  unaccountable  degree ; 
and  when  I  refer  to  the  works  of  authors  on 
the  subject,  it  is  but  to  a  scanty  source,  and 
supplying  little  information  applicable  to  our 
subject.  It  would  be  beyond  its  purpose  to 
introduce  in  this  work  an  attempt  to  supply 
this  defect,  nor  indeed  am  I .  prepared  to  do  so 
in  the  systematic  form  which  the  subject  re- 
quires ;  but  there  are  a  few  points  relating  to 
sound  which  must  be  known  before  we  can 
understand  those  phenomena  which  it  is  a 
great  object  of  this  work  to  explain, 

Sound  is  an  impression  communicated  to  our 
sense  of  hearing  by   certain  vibrations  of  mat- 


ON  THE  PROPERTIES  OF  SOUND.       17 

ter.  All  matter  is  susceptible  of  sonorous 
vibrations  ;  but  the  degrees  of  this  suscepti- 
bility are  as  varied  as  matter  is  diversified  in 
form  and  nature.  As  a  general  rule  it  may 
be  stated  that  it  is  in  proportion  to  the  strength 
of  the  molecular  elasticity  in  the  matter. 

This  term  molecular  elasticity  may,  perhaps, 
require  a  little  explanation.  I  mean  by  it  that 
force  by  which  the  molecules  of  a  body  are 
held  at  a  certain  distance  from  each  other,  and 
resist  any  effortto  displace  them  from  it.  Thus, 
glass  and  steel  may  be  said  to  possess  molecu- 
lar elasticity  in  a  powerful  degree,  because 
any  external  impulse  is  instantaneously  com- 
municated from  particle  to  particle  throughout 
their  whole  mass  ;  and  it  is  not  lost  or  broken 
by  the  yielding  or  displacement  of  the  mole- 
cules at  the  point  struck.  Air,  and  other  flu- 
ids, on  the  other  hand,  cannot  readily  be  thrown 
into  vibrations,  unless  the  impulse  be  applied  to 
some  extent  of  surface,  by  which  it  becomes 
communicated  to  many  particles  at  once. 

This  rule  is,  however,  much  too  abstract  to 
apply  directly  to  the  common  instances  of  the 
generation  of  sound ;  for  it  is  not  always  the 
hardest  bodies  thatproduce  the  loudest  sounds 
in  our  ears.  But  we  must  separate  the  physi- 
cal from  the  physiological  phenomenon,  in  order 
to  analyze  each  into  its  respective  elements.  I 
3 


18  ON   THE    PROPERTIES    OF    SOUJVD. 

conceive  that  the  motion  of  matter  producing 
sound,  should  be  considered  as  molecular,  al- 
though the  result  is  the  vibration  of  the  mass. 
I  would  explain  the  production  of  sound  as 
follows : — An  impulse  is  impinged  on  certain 
molecules ;  this,  momentarily  overcoming  the 
resistance  of  the  quiescent  forces,  causes  these 
molecules  to  start  from  their  place ;  that  force 
of  repulsion,  which  existing  between  the  differ- 
ent molecules  resists  the  attempt  to  approxi- 
mate them,  transfers  the  impulse  from  mole- 
cule to  molecuie,  and  thus  extends  it  through- 
out the  mass.  The  impulse  that  forced  these 
molecules  from  their  position  being  exhausted, 
they  spring  back,  by  virtue  of  their  attractive 
and  repulsive  forces,  to  beyond  their  original 
situation,  and  are  again  driven  back ;  until, 
by  a  series  of  these  alternating  vibratory  mo- 
tions, the  disturbing  force  is  lost. 

The  assimilatory  power,  then,  that  these  vi- 
brations possess  depends  on  the  molecular 
elasticity  of  the  body,  that  is  to  say,  on  the  re- 
pulsive and  attractive  forces  that  subsist  be- 
tween the  molecules  of  which  it  is  composed ; 
and  it  is  evident  that  this  assimilatory  or  propa- 
gating power  will  be  more  effective  in  propor- 
tion as  the  molecular  elasticity  is  strong  and 
perfect.  It  is  likewise  apparent  that  uni- 
formity,    or    equality    of    molecular    elasticity 


ON    THE    PROPERTIES    OF    SOUND.  19 

favours  the  propagation  of  sonorous  vibrations. 
For  if  the  elasticity  of  some  molecules  be  less 
than  that  of  others,  the  reaction  being  less,  will 
produce  vibrations  not  consentaneous  with 
those  of  the  others,  and  may  impair,  or  even 
destroy  them.  Let  us  illustrate  this  by  the 
vibrations  of  pendula.  Suppose  a  number  of 
pendula  suspended  in  a  line,  and  in  the  act  of 
vibration.  If  these  pendula  are  of  the  same 
length,  the  vibrations  will  be  equal  and  consen- 
taneous, and  will  neither  interfere  with,  nor 
interrupt  each  other.  Such  are  the  vibrations 
in  bodies,  whose  molecular  elasticity  is  uniform. 
But  suppose  the  pendula  of  different  lengths, 
and  the  vibrations,  therefore,  unequal,  the  mo- 
tions would  then  interfere  with  and  neutralize 
each  other,  and  this  the  more  effectually,  the 
more  varied  and  irregular  they  are. 

There  are,  however,  some  vibrations  that,* 
although  they  are  not  synchronous,  neverthe- 
less promote  each  other,  and  these  constitute 
what  are  called  harmonic  sounds.  To  show 
how  this  is  effected,  let  us  again  refer  to  the 
pendulum.  We  have  already  remarked  that 
pendula  of  the  same  length  vibrate  synchro- 
nousl}r,  and  may,  therefore,  promote  and 
strengthen  each  other.  This  is  the  harmony 
of  unison.  Suppose  one  pendulum  half  the 
length  of  the  other ;  it  makes  double  the  num- 


20  ON    THE    PROPERTIES    OF  SOUND. 

ber  of  vibrations  in  the  same  space  of  time,  and 
being  regularly  in  the  same  ratio  of  striking 
two  for  every  one  of  the  other,  the  vibrations 
do  not  counteract  each  other.  This  concord 
or  harmony  of  vibrations  of  sound  produces 
the  harmonic  note  of  the  octave.  The  same 
illustration  will  enable  us  to  conceive  the  har- 
monics of  the  fifth,  the  fourth,  and  the  third  ; 
the  ratio  of  their  vibrations  being  as  3  to  2,  4  to 
3,  and  5  to  4  of  the  key-note  ;  and  in  like  man- 
ner of  other  harmonics.  Now  it  is  necessary 
to  be  aware  of  these  relations,  in  order  to  un- 
derstand the  production  of  such  sounds  as  we 
are  accustomed  to  hear  ;  for,  owing  to  the  va- 
riable molecular  elasticity  of  the  bodies  in 
which  they  are  produced,  these  sounds  are 
always  compound,  and  consist  of  a  variety  of 
vibrations,  which  may  increase  or  neutralize 
each  other  according  as  the  arithmetical  rela- 
tions of  their  motions  harmonize  or  disagree. 
The  propagation  or  conduction  of  sound 
from  body  to  body,  is  subject  to  the  same  rule ; 
and,  in  fact,  it  consists  in  the  transmission  of 
the  same  impulse,  producing  sonorous  vibra- 
tions, from  one  body  to  another.  A  sound  will, 
therefore,  cceteris  paribus,  be  best  conducted 
by  those  bodies  which  approach  in  degree  and 
strength  of  molecular  elasticity  the  body  in 
which  that  sound  is  generated.     Thus  a  sound 


ON    THE    PROPERTIES    OF    SOUND.  21 

produced  in  air  will  be  best  propagated  by 
air  ;  one  produced  in  a  solid  will  be  most  com- 
pletely conducted  by  a  solid  of  the  same  den- 
sity and  hardness,  &c.  On  the  other  hand, 
bodies,  very  different  in  density,  receive  and 
transmit  sonorous  vibrations  very  imperfectly. 
Thus  air  transmits,  in  a  very  impaired  degree, 
the  sounds  produced  in  dense  bodies,  such  as 
metals  ;  and  the  sonorous  vibrations  of  air  are 
scarcely  received  by  dense  bodies. 

The  sounds  produced  by  the  collision  of 
solids,  and  transmitted  to  us  through  air,  are, 
nevertheless,  among  the  loudest  that  we  hear ; 
but  this  is  by  reason  of  the  law  before  stated, that 
those  bodies  are  most  susceptible  of  sonorous 
vibrations,  in  which  the  molecular  elasticity  is 
greatest,  as  well  as  most  uniform ;  and  such 
sounds  are  incomparably  louder  when  heard 
through  solids,  instead  of  through  air.  The 
transfer  of  sonorous  vibration  may,  however,  be 
greatly  favoured  in  another  way,  by  bringing  a 
large  surface  of  the  solid  vibrating  body  in  con- 
tact with  the  air,  and  otherwise  modifying  its 
form,  as  in  the  case  of  bells,  &c.  This  is  a 
separate  branch  of  acoustics,  and  is  not  suffi- 
ciently connected  with  our  subject  to  require 
notice  here. 

There  are  many  substances,  that  prove  bad 
conductors  of  sound,   from  their  being  of  un- 


22  ON  THE  PROPERTIES    OF  SOUND. 

equal  density ;  and  those  are  worst  in  which 
this  inequality  is  greatest.  Linen  and  woollen 
stuffs  are  examples.  The  threads  of  which 
they  are  composed  leave  interstices,  which  con- 
tain air  of  very  different  density  from  the  so- 
lid fibres.  In  paper  and  pasteboard,  the  same 
fibres  pressed  closer  together,  and  forming  a 
more  solid  mass,  become  a  far  better  conduc- 
tor. The  same  is  the  case  with  all  spongy 
bodies. 

It  now  becomes  apparent  why  the  loudness  of 
sounds  does  not  always  appear  to  us  propor- 
tioned to  the  hardness  and  density  of  the  bodies 
in  which  they  are  produced.  Air  is  commonly 
the  medium  through  which  sounds  are  con- 
ducted to  our  ears  ;  and  this  is  a  body  of  such 
tenuity  that  it  much  impairs  those  produced  in 
solids,  although,  physically,  they  are  the  loudest. 
We  are  thus  relieved  from  the  danger  of  injury 
to  our  organs  of  hearing,  from  sounds  that  might 
be  too  powerful  for  them  to  bear ;  and  this 
happy  provision  supersedes  the  necessity  of 
providing  them  with  a  defensory  apparatus  for 
their  occasional  occlusion,  which  we  findtobein 
various  degrees  necessary  for  the  other  organs 
of  sense.  In  most  of  the  loud  sounds,  therefore, 
which  we  are  accustomed  to  hear,  air  is  the  so- 
nific  body,  as  well  as  the  conducting  medium. 
The  sound  of  the  voice,  of  most  musical  instru- 


ON    THE    PROPERTIES    OF    SOUND.  23 

ments,  of  explosions,  &c,  originates  in  air.  In 
some  of  these,  such  as  explosions,  flutes,  and 
other  instruments  of  the  whistle  kind,  air  pro- 
duces the  sonific  impulse  as  well  as  the  sound, 
and  such  sounds  conveyed  by  air  may  be  of  a 
most  powerful  kind ;  but  can  be  only  imperfectly 
transmitted  by  solid  conductors.  In  the  sounds 
of  reed  instruments  (among  which  I  do  not  he- 
sitate to  class  the  human  voice),  airis  equally  the 
sonorous  body  ;  but  it  is  thrown  into  sonorous 
vibrations  by  the  mechanical  motions  of  a  solid, 
producing  little  or  no  sound  themselves.  The 
hum  of  insects  is  a  remarkable  example  of  the 
same  kind.  The  rapid  motions  of  their  wings 
produce  in  air  a  corresponding  series  of  vibra- 
tions, which,  when  it  attains  a  certain  degree  of 
rapidity,  produces  sound ;  and  this  sound  is 
more  acute  as  the  rapidity  is  greater  beyond 
this  degree.  The  vibration  of  cords,  I  believe 
to  be  in  the  same  predicament;  for  the  sounds 
which  they  produce  have  no  relation  to  the  so- 
norous qualities  of  the  substances  of  which  they 
are  formed  ;  but  entirely  to  the  elastic  tension 
in  which  they  are  longitudinally  kept,  and  by 
means  of  which  an  impulse,  deranging  their 
equilibrium,  occasions  a  series  of  transverse 
vibrations,  which,  communicated  to  air,  if  suffi- 
ciently rapid,  produces  sound. 

Sounds  produced  by  the  percussion  of  solids 


24       ON  THE  PROPERTIES  OF  SOUND. 

are  little,  if  at  all,  dependent  on  the  surrounding 
conducting  medium ;  but  they  become  modified 
in  intensity,  and  even  in  kind,  by  this  medium, 
according  as  it  differs  in  density  from  the  solid 
in  which  they  were  produced.  When  this  dif- 
ference is  great,  a  third  bodj',  of  intermediate 
density,  will  very  much  facilitate  the  transmis" 
sion  of  the  sound  to  our  ears.  Thus,  the  percus- 
sion of  hard  metallic  bodies  sounds  much  loud- 
er when  they  are  in  contact  with  wood,  because 
this  substance  of  intermediate  density  transfers 
the  vibrations  with  greater  facility  from  the 
metal  to  the  air.  I  may  give  the  common 
pitch  bar  as  an  example  of  this.  It  produces 
little  sound  after  it  is  struck,  as  long  as  it  is 
held  between  the  fingers,  but  no  sooner  is  it 
placed  on  its  end  on  the  table  or  pianoforte, 
than  its   sound  becomes  distinct  and  clear. 

I  am  thus  led  to  consider  the  power  of  dif- 
ferent media  to  conduct  sound,  not  as  an  abso- 
lute and  unchangeable  quality,  but  as  depen- 
dent on  the  relations  in  point  of  elasticity  of 
their  molecules  to  the  substance  from  which 
they    receive  the  sonorous  vibrations. 

The  reflection  of  sound  has  relation  to  the 
same  qualities  of  substances,  but  in  a  converse 
way.  When,  for  example,  a  sound  is  produced 
in  a  very  rare  medium,  such  as  air,  the  force  with 
which    the  vibrations  are  propagated  from  par- 


ON     THE    PROPERTIES  OF    SOUND.  25 

tide  to  particle,  is  weak,  because  the  molecular 
elasticity  is  weak,  and  being,  therefore,  incapa- 
ble of  communicating  its  vibrations  to  any  hard, 
dense,  and  incompressible  solid  with  which  it 
may  be  in  contact,  the  resisted  impulse  is  re- 
flected back  to  the  air  itself;  and  this  more 
perfectly,  the  greater  the  difference  in  molecu- 
lar elasticity  between  the  air  and  the  solid 
body.  The  laws  of  the  reflection  of  sound  are 
nearly  the  same  as  those  of  the  reflection  of 
light;  the  angle  of  reflection  being  equal  to 
the  angle  of  incidence  ;  and  this  analogy  great- 
ly facilitates  our  study.  I  must  observe,  how- 
ever, that  the  analogy  is  not  perfect  in  ob- 
servation ;  for  the  greater  materiality  of  the 
media  of  the  vibrations  of  sound  exposes  them 
to  a  greater  number  of  disturbing  influences, 
which  impair  or  disguise  the  operation  of  the 
law.  Thus,  from  motion,  difference  of  density, 
&c,  sound  seems  often  to  be  propagated 
through  air  in  curves,  instead  of  in  straight 
lines  ;  and  from  there  being  always  reflection 
where  there  is  diversity  of  matter,  sound  is 
more  easily  diffused  than  light. 


26  ON    PHYSICAL    SIGNS    IN   THE   CHEST, 

CHAP.  ir. 


ON   THE     PHYSICAL    SIGNS     OF     THE     STATE      AND 
ACTION    OF    THE    THORACIC   VISCERA. 

It  has  been  remarked  that  no  parts  of  the 
body  require  the  assistance  of  an  additional 
sense  to  discover  their  state  so  much  as  those 
contained  in  the  thorax.  Excluding  equally  with 
other  parts  the  scrutiny  of  vision,  and  by  reason 
of  their  bony  case  more  than  they  beyond  the 
reach  of  tact,  the  thoracic  viscera  would  have  re- 
mained in  more  than  the  common  obscurity  and 
uncertainty  of  signs  produced  by  equivocal  and 
inexplicable  sympathies,  and  still  more  fallacious 
sensations,  had  not  the  immortal  discoverers  of 
auscultation  and  percussion  pointed  out  the  pe- 
culiar adaptation  of  the  chest  to  afford  to  our 
organs  of  hearing  more  certain  indications  of  the 
state  of  its  contents.  And  so  effectually  is  the 
lacuna  filled  by  the  exercise  of  a  sense  that  may 
be  said  to  have  been  hitherto  useless  in  the 
physical  investigation  of  disease,  that  the  dis- 
eases of  the  chest  may  now  be  ranked  among 
those  most  within  our  powers  of  examination. 
For,  unlike  some  others  (the  brain  for  example), 
the  lungs  and  heart  have  no  such  complexity  of 


OX    PHYSICAL    ilOHfl    IX    THE    CHEST.  27 

structure,  or  obscurity  of  function,  as  to  render 
signs  of  their  physical  state  of  little  avail  to  ex- 
plain   their  disorder,    or   to   suggest   means  for 
their  cure.     We  see  in  these  organs  a  mechanism 
of  structure     admirably    adapted    for    its    own 
office ;  we  know  that  the  perfect  state  of  this 
mechanism  is  necessary  to  preserve  the  integrity 
of  the  function  ;    and  we  can  perceive,   when 
that   becomes  deranged,   how  this  must  neces- 
sarily suffer.    The  signs  by  which  such  derange- 
ments are  commonly  distinguished,  arise  not  so 
much  from  the   diseased  part  itself,  as  from  the 
disorder  which  it  may  produce  on  the  functions 
and  sensations.     Now,  as  it  is  impossible  to  find 
a  standard  by  which  to   judge  of  the  health  of  a 
function  in  individual  cases,   and  as   sensations 
are  frequently  so  elusive  as  to  baffle  our  attempts 
to  trace  them  to  their   source,  the  common  me- 
thod of  diagnosis  not  unfrequently  fails  to  detect 
even  the  existence  of  a  disease  ;  and  even  when 
the  signs  of  disordered  function  and  local  pain 
are  so  distinct  and  prominent  as  clearly  to  prove 
that  disease  is  present,  they  generally  leave  us 
in  more  or  less  doubt  as   to  its  nature.     They 
have  still  their  importance,  and  until  lately  have 
been   our   sole   guide   in  the  employment  of  a 
practice  by  no  means  unsuccessful.     Let  us  not 
then   exclude   these   from  our  view,   whilst   we 
study  other  signs  which  promise  us  still  greater 


28  ON    PHYSICAL    SIGNS   IN    THE    CHEST. 

certainty.  Ages  have  passed  away  without 
leaving  us  materially  improved  in  our  diagnosis 
after  the  old  method :  another  is  now  offered 
to  us,  on  the  more  certain  and  intelligible  basis 
of  physics,  which  discovers  signs  which  are  iden- 
tical with  the  physical  nature  of  the  disease. 

There  are  two  classes  of  sounds  from  which  a 
knowledge  may  be  obtained  of  the  state  of  the 
thoracic  viscera.  One  description  or  class  is,  for 
the  most  part,  naturally  produced  by  the  mo- 
tions of  the  organs  within  the  chest,  and  is  heard 
by  the  direct  or  mediate  application  of  the  ear 
to  its  parietes.  These  are  the  signs  of  ausculta- 
tion. The  other  class  of  sounds  is  produced 
artificially  by  striking  the  chest  ;  these  consti- 
tute the  signs  of  percussion.  These  last  I  shall 
first  notice,  not  that  they  are  prior  in  impor- 
tance, but  because  they  are  more  simple,  and 
are  generally  consulted  in  examination  before 
the  fuller  and  more  satisfactory  ones  of  auscul- 
tation. 

Section  I. — On  Percussion. 

The  chest  of  a  person  in  health  yields,  when 
struck  lightly  by  the  ends  of  the  fingers,  a 
hollow  and  somewhat  drum-like  sound.  The 
resonance  thus  produced  arises  from  the  air 
contained  within,  in  the  spongy  tissue  of  the 
lungs,  which  receives  the  impulse  through  the 


ON  PERCUSSION.  29 

thoracic  parietcs.  But  in  order  that  the  impulse 
be  propagated,  these  parietcs  must  possess  a  cer- 
tain degree  of  elastic  tension  ;  lor  if  they  are 
flaccid,  and  yield  to  the  stroke  of  percussion,  no 
sound  will  be  emitted  but  that  slight  and  obtuse 
one  produced  by  the  fall  of  the  fingers  upon  the 
surface.  The  natural  compact  of  the  chest, 
with  its  frame  of  bone,  attached  by  elastic 
ligaments  and  cartilages,  and  invested  by  a 
covering  more  or  less  tense,  of  muscles  and  in- 
teguments, is  generally  well  adapted  to  transmit 
to  its  interior  the  impulse  of  external  percus- 
sion :  but  if  the  elasticity  of  the  cartigales  be  in 
any  way  lost,  or  if  the  integuments  become 
thickened  by  oedema,  fat,  or  other  cause,  the 
resonance  on  percussion  will  be  proportionately 
diminished  ;  and  these  causes  of  modification 
of  the  pectoral  sound  must  be  carefully  sepa- 
rated from  those  depending  on  the  state  of  the 
internal  organs. 

In  the  natural  and  healthy  state,  as  the  clear- 
ness and  fulness  of  the  pectoral  resonance  on 
percussion  depends  on  the  air-filled  structure  of 
the  lung,  and  the  tenuity  and  tension  of  the  con- 
taining parietes,  it  is  evident  that  those  parts 
of  the  chest  will  sound  best  that  most  com- 
pletely present  these  conditions.  Our  anato- 
mical knowledge  will  therefore  point  out  the 
different   degrees  of    sound   that  the    different 


30  ON  PERCUSSION. 

parts  of  a  healthy  chest  should  emit.  Thus,  the 
anterior  and  axillary  parts  of  the  chest  should 
sound  well ;  but  in  most  of  the  posterior  region 
the  thickness  of  the  soft  parietes  must  render 
the  sound  more  dull,  and  the  same  effect  may  be 
produced  in  the  inferior  parts  by  the  contiguity 
of  the  abdominal  viscera.  For  a  more  specific 
detail  of  the  natural  sound  of  each  part  of  the 
chest,  I  refer  to  the  table  of  the  regions  into 
which  Laennec  has  divided  the  chest. 

The  manner  in  which  diseases  modify  the 
pectoral  resonance,  is  by  changing  the  density 
of  the  contained  organs.  If,  for  example,  a  liquid 
or  solid  effusion  take  place  in  any  part  of  the 
lungs  or  pleura,  the  corresponding  portion  of 
the  chest  will  yield  a  dull,  dead  sound,  and  with- 
out that  hollow  resonance  which  is  naturally 
produced  by  air  underneath.  On  the  other 
hand,  when  the  aeriform  contents  of  the  cavity 
are  increased  beyond  their  usual  proportion,  as 
in  pneumothorax  and  emphysema,  the  natural 
resonance  may  be  increased  to  a  degree  that 
sounds  quite  tympanitic. 

The  practice  of  percussion  requires  some 
manual  dexterity  ;  and  as  on  this,  in  great 
measure,  depends  the  correctness  of  its  indica- 
tions, I  shall  bestow  a  few  observations  on  the 
best  method  of  percussion.  It  is  of  very  little 
consequence  whether  the  patient  be  bitting  or 


METHOD    OF    PERCUSSION.  31 

standing,  or  sitting  up  in  bed,  provided  we  hold 
in  mind  that  all  the  sounds,  bad  and  good,  are 
rendered  somewhat  duller  in  the  latter  case,  by 
the  vicinity  of  the  pillows  and  bed-clothes, 
which  destroy  the  resonant  echo  accompany- 
ing sounds  in  more  empty  rooms.  The  same 
amount  of  difference  may  be  perceived  in  differ- 
ent rooms,  when  percussion  is  practiced  in  the 
standing  or  sitting  posture.  In  some  cases  of 
debility,  and  of  painful  disease,  the  patient  can 
bear  no  other  than  the  recumbent  posture  ;  and 
in  the  parts  where  percussion  can  be  practised, 
the  sounds  are  somewhat  more  dull  in  these 
cases,  from  the  deadening  effect  which  the  bed 
has  on  them.  Thus  warned,  a  little  practice 
will  enable  the  student  to  avoid  error  from  these 
causes. 

The  part  on  which  percussion  is  practised 
should  be  covered  with  a  linen  or  cotten  gar- 
ment *,  to  render  the  stroke  of  percussion  more 
equable,  and  to  prevent  its  producing  pain  ;  and 
for  this  purpose  a  shirt  or  bed-gown  kept  on, 
answers  ver}r  well,  if  care  be  taken  to  keep  it 
smooth  and  close  on  the  surface,  by  the  fingers 
of  the  left  hand. 


*  I  find  that  Dr.  Forbes  thinks  this  precaution  unnecessary  (Transla- 
tion of  Laennec).  I  believe  that  the  tact  furnished  by  experience  may,  as 
I  have  afterwards  observed,  supersede  this  and  other  precautions  ;  but  it 
is  necessary  for  a  beginner,  particularly  where  the  soft  parietes  of  the 
chest  are  thick. 


32  METHOD    OF    PERCUSSION. 

Percussion  is  generally  performed  with  the 
three  first  fingers  of  the  right  hand,  held  in  such 
manner  together,  that,  with  their  last  joints  at 
right  angles  with  the  surface  to  be  struck, 
their  tops  shall  fall  simultaneously  on  it.  The 
stroke  must  be  made  lightly,  and  with  a  jerk, 
by  drawing  the  hand  back  the  instant  it  has 
fallen,  as  if  it  struck  something  elastic  which 
repelled  it ;  ~and  by  a  stroke  thus  made,  as  mo- 
mentarily as  possible,  the  fullest  and  clearest 
sound  is  elicited.  It  is  of  importance  to  attend 
to  the  manner  in  which  the  phalanx  of  fingers 
falls  on  the  chest ;  more  or  less  in  the  transverse 
direction  of  the  ribs  is  generally  the  best  posi- 
tion ;  but,  above  all,  it  is  quite  indispensible 
that,  in  making  comparative  trials  of  the  two 
sides  of  the  chest  the  same  method  be  adhered 
to  ;  for  gross  errors  may  be  the  consequence  of 
striking  on  one  side  across,  and  on  the  other 
along  the  ribs,  as  the  sounds  often  differ  con- 
siderably when  produced  in  these  different  man- 
ners. I  might  go  into  minute  details  of  many 
modifications  which  I  have  found  advantageous 
in  the  employment  of  percussion  in  individual 
cases  ;  but  his  own  experience  will  furnish  such 
knowledge  to  each  observer  far  better  than  the 
most  elaborate  instructions  that  I  could  give. 
I  shall  only  remark  in  exemplification,  that  the 
examination  of  circumscribed  spots  can  be  best 


MEDIATE    PERCUSSION.  33 

effected  by  percussion  with  a  single  finger  (as 
on  the  clavicle,  a  rib,  &c),  whilst  a  general  and 
tolerably  accurate  survey  of  the  chest  may,  with 
economy  of  time,  be  often  obtained  by  percus- 
sion with  the  flat  hand,  avoiding,  in  this  case, 
the  jerk  necessary  in  the  other  method.  This, 
I  must,  however,  add,  should  be  trusted  to  only 
by  the*experienced  ear. 

Laennec  remarks  that,  besides  the  difference 
of  sound,  percussion,  on  a  healthy  hollow  chest, 
gives  a  peculiar  vibratory  sensation  to  the 
fingers  of  the  percussor,  quite  different  from  the 
dead  feel  of  percussion  over  a  part  of  the  chest 
destitute  of  elastic  air.  To  those  who  have 
sufficient  nicety  of  tact  to  perceive  this  distinc- 
tion, it  may  give  additional  evidence  not  without 
its  value. 

The  force  required  in  percussion  is  not  by 
any  means  to  an  amount  sufficient  to  produce 
pain  in  the  generality  of  instances  ;  but  there 
are  some  cases  in  which  the  parietes  of  the 
chest  are  particularly  tender,  and  here  percus- 
sion may,  with  advantage,  be  made  mediately, 
in  the  manner  recommended  by  M.  Piorrv. 
This  is  done  by  interposing  a  thin  lamina  of 
wood,  horn,  or  ivory  on  the  part  to  be  struck, 
so  that  while  the  impulse  of  percussion  is  per- 
fectly transmitted  to  the  interior  of  the  chest, 
it  is  so  diffused  on  the  surface  covered  by  the 
5 


34  MEDIATE    PERCUSSION. 

lamina  as  not  to  produce  pain.  The  same  con- 
trivance I  have  found  equally  useful  where,  on 
account  of  fat,  oedema,  &c,  unguarded  percus- 
sion could  not  be  practised  with  sufficient  force 
to  produce  the  resonance  of  the  interior,  with- 
out annoying  the  patient.  To  avoid  multi- 
plying apparatus,  I  have  always  used  the  horn 
ear-piece  of  the  stethoscope,  which  for  this  pur- 
pose I  have  made  very  thin  ;  and  to  prevent  the 
clacking  noise  produced  by  the  fall  of  the  fingers 
on  its  hard  surface,  I  have  it  lined  with  soft 
leather ;  and  thus  prepared,  I  have  found  this 
little  contrivance  perform  this  part  of  its  double 
office  better  than  any  pleximeter  that  I  have 
seen.  Held  by  means  of  its  raised  rim,  with  its 
concave  or  outer  side  in  close  apposition  to  the 
chest,  it  presents  its  inner  side  covered  with 
leather  for  percussion,  which  may  be  practised 
with  the  tops  of  the  fingers  as  usual,  or  with  any 
other  solid  object  of  convenient  form. 

Such  is  the  mode  of  obtaining  signs  of  the 
physical  state  of  the  contents  of  the  chest  by 
percussion.  The  indications  thus  obtained, 
although  they  only  relate  to  the  density  of  the 
parts,  are  of  great  value,  and  alone  may  some- 
times detect  disease  that  all  other  signs  leave 
in  obscurity.  But  their  importance  and  value 
are  vastly  enhanced,  when  they  are  combined 
with,  and  corrected  by,  the  more  numerous  and 


SIGNS    OF   AUSCULTATION.  35 

precipe  signs  discovered  by   auscultation  ;  these 
I  proceed  to  consider. 

Section  II. — On  Auscultation. 

The  signs  of  auscultation  are  those  sounds 
produced  in  the  chest,  which  may  be  heard  by 
the  direct  or  mediate  application  of  the  ear  to 
its  parietes.  Now,  1  shall  endeavour  (and  the 
same  will  be  my  object  throughout  this  little 
work)  to  trace  these  signs  to  their  physical 
causes,  and  bythus  exploring  the  relations  of 
diseases  to  certain  and  unchanging  laws  of 
natural  philosophy,  to  place  their  characters 
beyond  the  doubtfulness  and  obscurity  of  sym- 
pathetic and  sensatory  signs. 

I  have  before  remarked  that  the  sounds  heard 
by  auscultation  are,  for  the  most  part  produced 
by  the  natural  movements  of  the  organs  con- 
tained within  the  chest.  These  movements 
are,  those  of  respiration,  to  which  may  be 
added  the  voice  ;  and  those  of  the  heart.  Let 
us  consider  the  manner  in  which  these  several 
motions  give  rise  to  sound,  and  we  shall  then 
be  enabled  to  perceive  a  priori  the  modifica- 
tions in  it  that  disease  may  produce. 

The  ingress  and  egress  of  air  in  the  lungs 
cause  a  sound  of  a  peculiar  nature,  differing 
somewhat  according  to  the  part  in  which  it  is 
heard.      This    difference  arises  solely  from    a 


36  SIGNS    OF    AUSCULTATION. 

diversity  in  the  size  of  the  tubes,  through  which 
the  air  passes,  and  by  a  knowledge  of  this  we 
may,  therefore,  easily  judge  what  these  differ- 
ences ought  to  be.  Between  the  scapulae  (for 
example)  in  the  upper  part  of  the  axillse  and  in 
the  upper  sternal  region,  the  sound  is  hol- 
lower,  more  tubular  and  blowing,  because  in 
these  regions  many  bronchial  ramifications  of 
considerable  size  come  so  near  the  surface  of 
the  lung,  that  the  sound  produced  by  the  pas- 
sage of  air  through  them  is  heard  more  dis- 
tinctly than  the  duller  and  more  diffused  mur- 
mur which  has  its  seat  in  the  smaller  bronchi 
and  air  cells.  It  is  this  latter  sound,  on  the 
other  hand,  that  prevails  in  other  parts  of  the 
chest  ;  for  although  there  is  bronchial  respira- 
tion in  these  parts  likewise,  it  is  not  sufficiently 
near  to  the  surface  to  be  transmitted  through 
the  spongy  ^ind  ill-conducting  tissue  of  the 
lung. 

It  is  of  great  importance  to  be  able  to  dis- 
tinguish between  the  sounds  which  the  passage 
of  the  air  produces  in  the  trachea  and  larger 
bronchi  and  in  the  extreme  bronchi  and  vesicles  ; 
which  different  kinds  of  respiratory  sound, 
we  shall,  with  Laennec  and  Andral,  distinguish 
by  the  epithets  tracheal,  bronchial,  and  vesicu- 
lar. Rather  than  attempt  to  convey  an  idea  of 
these  sounds   by   description,   I  will  refer  for 


SOUND    OF    RESPIRATION.  37 

the  illustration  of  tracheal  respiration,  to  the 
anterior  and  lateral  parts  of  the  neck,  the 
superior  sternal  region,  the  sternal  portion 
of  the  subclavian  regions,  and  the  cervical 
portion  of  the  acromian  regions  ;  of  bronchial 
respiration,  to  the  middle  portion  of  the 
sternum  and  those  parts  of  the  mammary 
regions  contiguous  to  it,  and  in  thin  subjects 
to  the  principal  part  of  the  interscapular  and 
axillary  regions  ;  and  of  vesicular  respiration 
to  the  remaining  parts  of  the  chest.  Such 
are  generally  the  situations  of  the  different 
kinds  of  repository  sound ;  but,  as  might 
be  expected,  the  distinction  may  be  much 
more  easily  made  in  some  subjects  than  in 
others,  and  the  characters  can  in  a  correspond- 
ing degree  be  severally  recognized. 

There  is  a  considerable  difference  in  the  in- 
tensity of  the  sound  of  respiration  in  different 
individuals  ;  and  this  depends  partly  on  the 
thickness  of  the  parietes  of  the  chest,  but 
principally  on  the  degree  of  activity  of  the 
respiratory  function.  Increased  thickness  of 
the  parietes  of  the  chest  by  fat  or  oedema  does 
not  very  materially  impede  the  transmission  of 
sound  of  respiration  to  the  ear,  for  being  nearly 
of  equal  density,  they  form  still  a  pretty  good 
conductor  of  sound.  From  the  same  circum- 
stance, the  respiratory  murmur  is  most  distinctly 


38  SIGNS    OF    AUSCULTATION. 

heard  in  those  parts  otthe  chest  where  the  pa- 
rietes  are  thinnest. 

The  degree  of  activity  in  the  function  in  a 
much  more  remarkable  manner  determines  the 
intensity  of  the  respiratory  sound  ;  and  the 
variety  which  different  individuals  in  this  re- 
spect present,  even  in  health,  is  a  matter  of 
much  physiological  interest.  We  know  that  in 
like  manner  other  secernent  functions,  as  those 
of  the  kidneys  and  skin,  vary  in  different  indivi- 
duals, under  the  same  circumstances,  in  the  de- 
grees of  their  activity,  and  we  may  range  the 
present  instance  amongst  them.  Were  we  to 
enquire  still  further  into  the  causes  of  these 
differences,  we  should  probably  be  led  to  con- 
clude that  they  all  have  relation  to  a  certain 
standard  of  organic  activity  or  irritability,  in 
some  manner  dependent  on  the  physical  consti- 
tution of  the  body.  From  this  obscure  point 
of  constitutional  difference  (which  we  can  only 
generalize,  and  not  explain)  let  us  turn  to  some 
changes  in  the  respiratory  sound  that  may  take 
place  in  the  same  individual  within  the  bounds 
of  health. 

I  have  remarked  that  it  is  more  distinct  after 
meals  than  at  other  times,  which  fact  accords 
well  with  an  ascertained  point  in  animal  che- 
mistry ;  and  proving  that  a  greater  activity  of 
function    is   at  that  time  required,   it    likewise 


SOUND    OF    RESPIRATION.  39 

furnishes  an  additional  reason  why  persons 
affected  with  habitual  dyspnoea,  should  then 
most  feel  the  incapacity  of  their  organs.  Mo- 
derate exercise  likewise  increases  the  respira- 
tory sound  ;  but  violent  exertion  has  a  tendency 
to  produce  an  opposite  effect ;  for,  when  the 
muscles  of  respiration  are  exerted  beyond  a 
certain  degree  of  activity,  the  dilatation  and 
contraction  of  the  lung  cannot  always  keep 
pace  with  them,  and  the  bronchial  muscles  are 
thrown  into  a  state  of  irregular  spasmodic  con- 
traction (probably  increased  by  the  congestion 
of  blood  in  the  lungs,)  which  is  gradually  re- 
lieved by  the  returning  moderation  and  regula- 
rity of  the  respiratory  effort.  This  is  much 
more  remarkable  in  persons  unaccustomed  to 
exertion  and  advanced  in  life,  than  in  the  young 
and  active  ;  and  I  think  we  should  not  use  too 
mechanical  a  term,  if  we  say  that  this  proceeds 
from  the  greater  rigidity  of  the  lungs  in  the 
former.  This  leads  me  to  the  remarkable  pe- 
culiarity that  the  respiration  of  very  young  in- 
dividuals presents  to  the  auscultator. 

From  birth  till  about  the  period  of  puberty, 
the  sound  of  respiration  is  much  louder,  and 
more  shrill  than  in  after  life  ;  the  passage  of  the 
air,  producing  it,  seems  much  quicker,  and  the 
function  appears  to  be  in  an  extreme  of  activity. 
That    the     sound    of  puerile    respiration     (as 


40  SIGNS  OF   AUSCULTATION. 

Laennec  terms  this  modification,)  proceeds 
from  no  peculiarity  in  the  structure  of  the 
lungs  of  children,  is  proved  by  the  fact  that  it 
is  occasional^  produced  in  adults,  when  one 
part  of  the  lung  is  called  into  increased  activity, 
to  supply  the  defect  of  another  incapacitated 
by  disease.  So  also  in  adults,  after  a  temporary 
suspension  of  respiration,  as  in  reading  or  con- 
tinued utterance,  the  respirations  are  often 
attended  with  a  puerile  sound ;  for  being  more 
rare,  they  are  made  with  greater  perfection  and 
energy  than  usual.  About  the  age  of  puberty 
the  sound  of  respiration  becomes  deeper  and 
less  noisy,  and  in  a  few  years,  sooner  or  later, 
gradually  assumes  the  character  of  adult  re- 
spiration. 

This  change  I  am  disposed  to  attribute  prin- 
cipally to  a  greater  comparative  development 
of  the  lungs  at  that  age,  rather  than  to  a  dimin- 
ished activity  of  their  function.  It  is  at  this 
period  that  the  muscular  system  developes  itself 
more  fully,  and  to  support  the  occasional  exer- 
tion of  its  augmented  power,  the  organs  of  the 
chest  acquire  an  increased  capacity,  and  a  more 
extended  sphere  of  activity.  The  pulse  and 
respiration  becoming  slower  in  their  standard 
of  rest,  offer  a  greater  range  in  their  dynamo- 
metric  scale,  and  although,  from  increased  ca- 
pacity,  their    common    activity  is   diminished, 


SOUND     OP    INSPIRATION. 


41 


they  have  greater  capabilities  in  reserve  to  sup- 
port the  occasional  exertions  of  increased  mus- 
cular strength.  We  find,  accordingly,  that  in 
young  persons  above  the  age  of  puberty,  in- 
creased exertion  renders  the  respiration  puerile, 
(that  is,  more  active),  and  is  therefore  easy ;  and 
as  long  as  this  supplementary  power  of  the 
lungs  is  moderately  exercised,  by  occasional  in- 
creased muscular  exertion,  it  will  be  preserved  ; 
but,  on  the  other  hand,  it  will  be  lost  by  disuse  ; 
the  organs  will  become  rigid  in  their  limited 
sphere  of  action  ;  occasional  exertion  will  be 
attended  with  the  anhelation  and  spasmodic  ac- 
tion of  the  bronchi  before  alluded  to  ;  and  the 
attacks  of  disease,  on  a  function  that  can  scarcely 
bear  abridgment,  must  be  left  with  a  greater 
degree  of  severity : — an  addition  to  the  volume 
of  arguments  in  favour  of  regular  and  active 
exercise. 

As  the  sound  of  vesicular  respiration  is  pro- 
duced by  the  perfect  penetration  of  the  air  into 
the  lungs,  its  simple  and  equal  presence  may  be 
regarded  as  an  index  of  the  healthy  perform- 
ance of  the  function  ;  and  as  no  physical  change 
can  interrupt  or  modify  this  function  without 
interrupting  and  modifying  the  sound,  the  study 
of  these  latter  changes  will  lead  us  to  a  knowledge 
of  the  physical  changes  that  produce  them. 

The   total  absence  of  respiratory  sound  in  a 
6 


42 


SIGNS    OF    OSCULTATION, 


part,  indicates  that  the  air  no  longer  penetrates 
there,  either  because  something  excludes  its 
entry  into  the  pulmonary  tissue,  or  because  this 
tissue  is  pushed  away  from  the  parietes  of  the 
chest  by  an  effusion  into  the  pleura.  An  ap- 
peal to  the  signs  of  percussion  is  here  necessary 
to  ascertain  in  what  manner  the  lung  is  in- 
vaded or  surrounded.  If  the  sound  on  percus- 
sion remains  natural,  the  obstruction  is  pro- 
bably situated  in  some  of  the  bronchial  branches 
leading  to  the  part,  whilst  the  vesicular  texture 
contains  its  due  quantity  of  air;  if  it  is  dull, 
there  is  liquid  or  solid  effusion,  either  in  the 
vesicular  structure  of  the  lung,  or  in  the  inter- 
vening pleural  space ;  but  if  it  be  clearer  than 
usual,  there  is  either  emphysema  of  the  lung,  or 
an  aeriform  effusion  in  the  pleura.  The  inquiry 
thus  simplified  can  now  be  specifically  directed 
to  the  distinctive  characters  of  individual  dis- 
eases, presenting  either  of  these  physical  con- 
ditions. 

Sometimes  the  sound  of  natural  vesicular 
respiration  is  absent,  and  a  kind  of  hissing 
bronchial  respiration  is  heard  instead.  Now, 
as  the  sound  of  the  passage  of  the  air  in  the 
bronchial  tubes  cannot  be  usually  heard  through 
the  spongy  and  ill-conducting  vesicular  texture, 
it  must  be  supposed  that  either  the  bronchial 
respiration  is  louder  than  usual  in  these  cases. 


SOUNDS    OF  RESPIRATION.  43 

or,  that  the  tissue  of  the  lung  is,  by  some  change, 
rendered  a  better  conductor  of  sound.  But  in- 
creased loudness  of  the  bronchial  respiration 
would  not  explain  the  absence  of  the  sound  of 
the  vesicular.  Abandoning,  therefore,  this  al- 
ternative, we  shall  find  in  the  other  an  explana- 
tion of  both  modifications  ;  for  a  liquid  or  solid 
effusion,  at  the  same  time  that  it  obstructs  the 
entry  of  air  into  the  cells,  likewise  so  condenses 
the  tissue  as  to  enable  it  to  transmit,  from  its 
interior,  sounds  that  are  not  usually  heard. 

A  sound,  resembling  that  of  tracheal  respira- 
tion, is  sometimes  induced  by  disease,  in  parts 
where  vesicular  respiration  alone  is  naturally 
heard  ;  and  this  phenomenon  is  caused  by  the 
passage  of  the  air  in  a  cavern  or  ulcerated  ca- 
vity communicating  with  the  bronchi.  The 
sound  thus  produced,  which  is  called  cavernous 
respiration,  is  so  remarkable,  and  so  like  the 
blowing  of  air  into  any  little  hollow  object,  that 
the  mind  would  at  once,  and,  as  it  were  in- 
stinctivelv,  refer  it  to  its  true  cause. 

There  is  a  remarkable  class  of  sounds  pro- 
duced by  partial  obstructions  to  the  passage  of 
the  air  through  the  bronchial  ramifications. 
These  sounds,   which   are  called  rhonchi*,  may 

*I  prefer  the  Latin  term  rhonchus  to  the  French  role,  and  the  English 
rollle ;  for  it  both  expresses  the  subject  better,  and  is  more  accordant  with 
the  usual  stylo  of  medical  language.     If  an  English  term  must  be  used, 


44  SOUND    OF    RESPIRATION. 

be  divided  into  the  dry  and  humid.  The  dry 
rhonchi  are  those  sounds  produced  by  the  pas- 
sage of  the  air  through  bronchi,  which  have 
some  part  of  their  calibre  contracted  by  a  sub- 
stance more  or  less  solid.  This  contraction  may 
be  produced  by  a  partial  tumefaction  of  the 
membranes  of  a  bronchus,  by  the  pressure  of  an 
adjacent  tumour,  or  by  some  body,  such  as  a  por- 
tion of  thick  mucus,  within  its  tube  ;  and  the  form 
and  size  of  the  isthmus,  or  contracted  point, 
will  determine  the  nature  of  the  sound.  Thus, 
we  often  hear  an  acute  whistling  sound,  which 
is  therefore  called  the  sibilant  rhonchus  ;  and 
as  we  know  that  such  a  sound  may  be  produced 
by  air  passing  through  a  small  circular  aperture*, 

the  word  wheeze,  adopted  by  the  editor  of  the  Medico-Chirurgical  Review, 
is  the  least  exceptionable.  To  that  editor  the  profession  is,  and,  in  course 
of  time,  will  hold  itself  indebted  for  the  candid  and  philosophical  spirit, 
in  which  he,  at  an  early  period,  recognised  and  proclaimed  the  advantages 
of  auscultation. 

*  It  must  be  observed,  that  to  produce  a  whistling  sound  by  the  pas- 
sage of  air  through  a  round  aperture,  there  must  be  a  certain  proportion 
between  the  velocity  of  the  air  and  the  size  of  the  aperture.  I  may  re- 
mark here,  that  I  think  Dr.  Forbes  mistaken  in  translating  sibilant  by 
the  word  hissing.  The  rhonchus,  called  here  sibilant,  and  frequently 
pointed  out  to  me  by  Laennec  as  such,  is  a  perfect  whistle  ;  whilst  the 
sound  of  bronchial  respiration  has  more  of  the  hissing  character.  Hissing 
and  whistling,  however,  approach  each  other  in  their  physical  cause ;  the 
principal  difference  consisting  in  the  more  forcible  passage  of  air  through 
a  more  flattened  orifice  in  the  former.  The  two  terms  are  identified  in 
Latin  and  in  French  by  the  words  sibilare  and  siffler.  The  English  have 
now  so  set  apart  the  former,  as  a  powerful  means  of  expression,  from  the 
latter,  which  may  be  made  by  no  means  contemptible  for  music,  that 
they  could  not   now  well  spare  the  distinction. 


iuioxchi.  45 

it  may  be  supposed  that   a  contraction  of  this 
kind  causes  it  in  this  case. 

The  sonorous  rhonchus,  which  sometimes  re- 
sembles snoring,  sometimes  the  buzzing  of  an 
insect,  sometimes  the  bass  note  of  a  violoncello 
or  bassoon,  is  rather  produced  by  a  flattened 
contraction  in  a  bronchus  of  considerable  size. 
This  contraction,  which  leaves  little- or  no  gap- 
ing aperture,  throws  the  air  passing  through  it 
into  sonorous  vibrations,  after  the  manner  of 
the  reed  of  the  hautboy,  or  the  lips  in  blowing  a 
horn  or  trumpet ;  or,  perhaps,  the  production  of 
this  sound  is  still  more  completely  represented 
in  the  manner  in  which  a  celebrated  ventrilo- 
quist imitates,  with  his   lips,  the  buzzing  of  a 

The  dry  mucous  rhonchas  may  be  said  to  be  a 
coarse  modification  of  the  preceding.  It  re- 
sembles the  sound  of  a  click  wheel  ;  and  is 
produced  by  a  portion  of  very  viscid  mucus 
attached  to  the  interior  of  a  bronchial  tube, 
which  yielding  with  a  jerking  resistance  to  the 
air  forcing  its  passage,  thereby  causes  a  tick- 
ing sound.  Such  is,  in  fact,  the  analysis  of  the 
sonorous  rhonchus;  for  it  only  requires  that  the 
air  should  pass  more  speedily,  and  the  tickings 
be  multiplied  until  they  seem  continuous,  to 
convert  the  dry  mucous  into  the  sonorous 
rhonchus. 


46  SOUNDS    OF    RESPIRATION. 

The  humid  rhonchi  arise  from  the  presence  of 
fluids  in  the  bronchial  tubes.  The  commonest, 
and  the  most  obvious  in  its  nature,  is  the  mu- 
cous or  bubbling  rhonchus,  a  sound  which  the 
mind  at  once  refers  to  the  passage  of  air  in 
bubbles  through  a  liquid.  It  is  more  gurgling, 
coarse,  and  irregular,  when  situated  in  bronchial 
tubes  of  large  size,  because  the  bubbles  are  large 
and  unequal.  In  the  smaller  order  of  bronchial 
tubes,  on  the  other  hand,  it  is  more  equal  and 
minute.  So  we  can  perceive  at  once  what  kind 
of  sound  this  rhonchus  ought  to  have  when  in 
the  trachea  or  in  a  cavity  produced  by  disease. 
It  is  coarse  and  gurgling,  in  proportion  to  the 
size  of  the  tube  or  cavity  in  which  it  is  pro- 
duced, and  the  freedom  with  which  the  air 
passes  through  the  liquid  ;  and,  when  presenting 
these  conditions,  the  cavernous  rhonchus,  gar- 
gouittement,  or  mucous  rhonchus  of  caverns,  is 
one  of  the  most  remarkable  and  important  signs 
discovered  by  auscultation.  It  would  seem  un- 
necessary to  inquire  further  into  the  physical 
nature  of  the  mucous  rhonchus,  were  it  not  that 
the  inquiry  may  enable  us  to  distinguish  some 
of  its  varieties  from  another  rhonchus  ;  which 
distinction  is  an  object  of  considerable  impor- 
tance. 

The  sound  of  the  mucous  rhonchus  depends  on 
the  bursting  of  successive  bubbles  of  air  which 


MUCOUS    RHONCHUS.  47 

pass  through  a  liquid.  A  bubble  is  a  portion  of 
air  contained  by  a  thin  film  of  liquid,  which  pre- 
serves its  continuity  by  virtue  of  its  attraction 
of  aggregation  ;  and  the  bursting  of  this  bubble 
is  the  overcoming  of  the  resistance  of  this  power 
by  some  other,  so  that  the  air  escapes.  At  the 
moment  of  its  escape  by  the  bursting  of  the 
film,  its  slight  expansion  communicates  to  the 
body  of  air,  of  which  it  is  now  become  a  part, 
an  impulse  which,  if  sufficiently  forcible,  pro- 
duces a  sound.  Now  this  impulse  will  be 
forcible  in  proportion  to  the  resistance  offered 
by  the  film  of  liquid  at  the  moment  of  its  rup- 
ture, and  will  therefore  be  greatest  when  the 
bursting  force  is  applied  so  quickly  and  sud- 
denly that  it  meets  with  the  full  resistance  of 
the  newly  formed  film,  undiminished  by  the  ex- 
tenuating power  of  gravitation. 

Now  the  bubbles  of  the  mucous  rhonchus  are 
both  formed  and  burst  by  the  respiratory  move- 
ments driving  air  through  the  liquid  in  the 
bronchial  canals  ;  and  they  will  therefore  pro- 
duce most  sound  in  those  bronchi  through 
which  the  air  passes  most  quickly.  These  are, 
of  course,  the  bronchi  of  larger  order.  If  the 
liquid  be  thin  and  watery,  the  bubbles  pass,  and 
burst  in  quick  succession,  with  an  irregular  and 
more  or  less  gurgling  sound  ;  but  if  it  be  viscid 
they  are  fewer  in  number,  and  may  be   carried 


48  SOUNDS    OF    RESPIRATION* 

on  in  the  tube  some  way  before  they  burst;  and 
the  sound  is  therefore  diffused  more  regular, 
and  rare.  The  quantity  of  liquid  present  in  the 
bronchi  may,  in  some  measure,  be  estimated  by 
the  continuance  of  the  rhonchus.  If  this  ac- 
company only  the  first  part  of  inspiration  and 
the  end  of  expiration,  the  liquid  must  be  scanty, 
for  it  only  interferes  with  the  air  when  the  tubes 
are  in  their  contracted  state  :  But  if  the  whole 
of  the  respiratory  act,  even_  to  the  acme  of  in- 
spiration, is  attended  with  the  bubbling  sound, 
then  it  must  be  apprehended  that  the  quantity 
of  liquid  is  considerable,  and  extends  to  the 
small  bronchi. 

A  little  liquid  in  the  smaller  bronchial  tubes 
produces  the  submucous  rhonchus,  a  kind  in 
which  the  bubbles  are  fine  and  more  crepitant ; 
but  they  often  intermit,  and  in  a  full  breath  are 
diminished  to  a  slight  roughness,  accompanying 
the  respiratory  murmur. 

The  rhonchi  of  which  I  have  yet  spoken, 
with  the  exception  of  the  submucous,  are  ge- 
nerally produced  in  bronchial  ramifications,  of 
above  or  about  the  size  of  a  crow's  quill ;  it  is 
in  those  below  these,  or  perhaps  in  the  necks 
of  the  bunches  of  vesicles  themselves  that  the 
crepitant  rhonchus  has  its  seat.  This  is  like- 
wise a  bubbling  rhonchus  >  but  it  is  physically 
and  pathologically  different  from  all  the  others 


CREPITANT    RHOXCHUS.  49 

The  sound  is  a  gentle  crepitation,  uniform  and 
continuing  to  the  end  of  inspiration.  It  is 
compared  by  Laennec  to  the  crepitation  of  salt 
by  heat,  and  the  resemblance  is  pretty  exact 
when  common  grain  salt  of  commerce  is  thrown 
on  a  heated  iron.  It  may  also  be  tolerably  re- 
presented by  rubbing  transversely  between  the 
fingers  and  thumb  a  lock  of  one's  hair  close 
to  the  ear.  It  is  probable  that  in  the  cases  in 
which  the  crepitating  rhonchus  is  present,  the 
calibre  of  the  last  bronchial  division  is  so 
much  diminished  (by  the  interstitial  effusion) 
that  the  air  cannot  pass  through  them,  without 
raising  the  mucus,  more  or  less  viscid,  into 
bubbles ;  which,  being  uniformly  small,  and 
bursting  regularly,  produce  a  continued  succes- 
sion of  minute  crepitations.  The  more  viscid 
the  mucus,  the  more  distinct  is  the  crepitant 
character  of  the  rhonchus.  It  is  perfectly  so 
in  the  crepitant  rhonchus  of  pneumonia.  In 
pulmonary  apoplexy  and  oedema,  on  the  other 
hand,  the  liquid  of  the  bronchi  is  thinner,  and 
the  rhonchus  being  less  perfect  in  its  crepita- 
tion, is  accordingly  called  subcrepitant. 

Thus  the  rhonchi  give  positive  and  direct 
indications  of  the  state  of  the  bronchial  tubes  ; 
nor  can  these  suffer  materially  without  either 
altered  secretion  or  change  in  calibre  producing 
one  or  other  of  these  rhonchi.     Respiration  thus 


RABY 

50  AUSCULTATION    OF    THE    COUGH. 

modified  is  generally  more  noisy  than  when 
free,  and  a  rhonchus,  particularly  the 'sibilant 
or  sonorous,  may  often  be  heard  through  the 
spongy  texture  of  a  whole  lung.  This  does 
not,  however,  prevent  the  natural  respiration 
of  the  healthy  parts  from  being  heard :  for  as 
long  as  two  sounds  differ  in  nature,  the  louder 
will  not  drown  the  weaker,  unless  the  dispro- 
portion be  great.  For  example,  the  sound  of 
respiration  may  be  heard  although  a  much 
louder  sibilant  rhonchus  accompany  it:  and  a 
deep  seated  rhonchus  crepitans  can  often  be 
distinguished  in  spite  of  the  respiratory  mur- 
mur immediate^  below  the  stethoscope.  We 
frequently  hear  a  mixture  of  several  rhonchi, 
occupying  adjacent  tubes ;  and  it  sometimes 
requires  considerable  attention  to  separate  and 
recognize  them. 

The  modification  of  respiration  which  con- 
stitutes cough,  may  often  be  consulted  with 
advantage  when  the  sounds  produced  in  the 
ordinary  respiratory  act  are  doubtful  or  in- 
distinct. Cough  consists  of  a  sudden  and  for- 
cible expiration,  succeeded  by  a  deep  but  quick 
inspiration.  Now  as  in  this  case  the  passage 
of  the  air  is  more  forcible  and  perfect,  the 
sounds  produced  by  it  must  likewise  be  ren- 
dered more  distinct  than  in  common  respira- 
tion ;    and  not  unfrequently    cough  may  force 


AUSCULTATION    OF    THE    VOICE.  51 

• 

air  through  bronchi,  too  much  obstructed  to 
admit  it  by  the  common  respiratory  effort. 
The  cough  may,  of  course,  be  modified  in  the 
same  way  as  common  respiration  ;  and  may, 
therefore,  be  accompanied  by  the  sibilant,  sono- 
rous, crepitant  and  mucous  rhonchi.  It  disco- 
vers the  existence  of  caverns  more  unequivo- 
cally than  common  respiration  does,  whether 
the  caverns  be  empty  and  yield  only  the  hollow 
resonance  of  air  blowing  in  them,  or  whether, 
containing  a  liquid,  they  are  the  seat  of  the  gurg- 
ling cavernous  rhonchus. 

The  voice  is  another  source  of  signs  by  which 
the  auscultator  may  judge  of  the  state  of  the 
lungs.  The  sound  of  the  voice,  although  pro- 
duced in  the  larynx,  is  propagated  to  the  air 
in   the   trachea   and   bronchial  tubes*,    as   out- 

*  I  do  not  at  all  concur  in  M.  Laennec's  opinion,  that  the  bronchial 
tree  is  a  part  of  the  instrument  that  originates  the  sound  of  the  voice  ;  for 
if  it  were  so,  disease  would  affect  the  voice  in  a  very  different  manner 
from  what  we  find  to  be  the  case.  The  hepatization  of  a  lung,  or  its 
compression  by  a  pleuretic  effusion  should  in  that  case  raise  its  tone  to  a 
treble.  I  have  often  known  them  to  exist  without  changing  it  at  all. 
It  is  true  that  large  ulcerous  excavations  do  sometimes  render  the  voice 
deep  and  hollow  ;  but  this  is  because  the  want  of  breath  prevents  the 
patient  from  contracting  the  glottis  sufficiently  to  produce  more  acute 
tones.  To  receive  as  much  air  as  possible  to  fill  the  healthy  cells,  as  well 
as  the  vast  excavations  in  which  it  is  wasted,  the  glottis  either  contracts 
only  enough  to  produce  a  low  bass  note,  or  does  not  contract  at  all,  and 
the  patient  then  speaks  in  a  whisper.  I  conceive  that  the  trachea  and 
bronchi,  besides  supplying  the  air  for  the  production  of  the  voice  in  the 
larynx,  act  something  after  the  manner  of  a  sounding  board  in  musical 
instruments,  reverberating  and  giving  fulness  to  the  voice,  but  not  essen- 
tially producing  or  changing  its  diapason. 


52  AUSCULTATION    OF    THE    VOICE. 

wardly  it  is  communicated  to  that  in  the  mouth 
and  beyond  it.  Accordingly,  if  we  listen  with 
the  stethoscope  applied  to  the  trachea  or  upper 
part  of  the  sternum,  we  hear  the  voice  through 
the  instrument,  and  louder  than  by  the  other 
ear,  inasmuch  as  the  voice  is  outwardly  diffused 
in  a  large  space,  but  there  confined  within  a 
narrow  tube.  If  the  stethoscope  be  applied  to 
those  parts  of  the  chest  under  which  pass  bron- 
chial tubes  of  considerable  size,  the  voice  will 
be  heard  there  likewise,  but  it  is  not  so  loud, 
and  its  articulation  is  less  distinct.  Over  smaller 
branches,  the  articulation  is  still  further  con- 
fused, and  the  voice  is  heard  only  in  a  diffused 
resonance.  In  the  vesicular  structure  they  are 
both  lost,  and  over  this  a  slight  fremitus,  which 
the  voice  produces  throughout  the  chest,  can 
alone  be  heard.  The  vocal  resonance  does  not 
extend  to  the  smaller  bronchi,  because  they  do 
not  afford  sufficient  space  for  its  vibrations  ; 
and  also,  because  their  less  tense  and  more 
membranous  tunics  are  ill  adapted  to  reflect 
sound. 

The  vesicular  texture  is,  as  we  have  already 
seen,  a  very  bad  conductor  of  sound  ;  hence 
it  prevents  the  vocal  resonance  in  the  bronchi 
from  being  transmitted  to  the  parietes  of  the 
chest;  except  in  those  parts  where  bronchi 
of  some   size   pass    close   to   the    surface.      It 


AUSCULTATION    OF    THE    VOICE.  53 

therefore  appears  that  different  parts  of  the 
chest  will  present  to  the  auscultator  some 
varieties  of  this  vocal  resonance,  and  it  is 
important  that  he  should  be  acquainted  with 
them. 

When  the  stethoscope  is  applied  to  the 
larynx  or  trachea,  the  voice  seems  to  enter  the 
instrument  as  loudly  as  if  the  speaker's  mouth 
were  applied  to  it.  This  phenomenon  scarcely 
ever  exists  to  its  full  extent  in  any  part  of  the 
chest  unless  in  a  state  of  disease  ;  and  it  is  there- 
fore useful  to  distinguish  between  it  and  the 
natural  bronchophony,  which  is  to  be  heard  un- 
der and  near  the  upper  partof  the  sternum,  in 
the  upper  part  of  the  axilla,  and  in  the  intersca- 
pular space.  In  these  situations,  the  voice  is 
generally  louder  than  that  which,  proceeding 
from  the  mouth,  strikes  the  other  ear,  but  the 
words  seem  to  be  at  the  end  of  the  tube,  and 
not  as  in  lary?2gophony,  to  pass  through  it  into 
the  ear.  Such  is  the  impression,  and  although 
it  is  illusory,  and  arises  only  from  a  difference 
in  the  body  of  sound,  it  should  be  attended 
to,  as  enabling  us  to  make  an  important  distinc- 
tion. 

The  degree  of  rocal  resonance  in  the  chest 
differs  considerably  in  different  individuals,  and 
the  causes  of  this  difference  are  not  obscure.  It 
is  loudest,  and  most  distinct  and   extensive  in 


54  AUSCULTATION    OF   THE    VOICE, 

those  persons  that  are  thin,   and  have  a  sharp 
treble  voice  ;  and  if  these  circumstances  exist  in 
a  great  degree,  the   natural  bronchophony  may 
extend  to  the  mesial  parts  of  the  scapular,  infra- 
clavian,   and   mammary  regions,  whilst    in   the 
usual  places  it  almost  amounts  to  laryngophony. 
It  is  therefore    remarkable  in  young   subjects 
and  in  females;     In  those,  on  the  other  hand, 
whose  chests  are  well  clothed  with  muscles  and 
fat,  and    whose    voices   are    deep,   the   natural 
bronchophony  is    obscure  and   confined.      The 
vibrations  of  deep  notes   cannot  be  extended  to 
very  narrow  tubes,  because  there  is  not  space 
for  their  play  ;    and  this   explains  the  difference 
resulting  from  the  tone  of  voice,   and  suggests 
that  a  change   of  tone  in  the   same   individual 
ma}r  considerably  vary  the  bronchophonic   re- 
sonance.    In  all  other  parts   of  the  chest  there 
is  either  no  resonance,   or  only  that  slight  vibra- 
tory fremitus  or  thrill  that  may  likewise  be  felt 
on  the  application  of  the  hand   to  the  parietes 
during  the  exercise  of  the  voice.     This   vibra- 
tion, which  accompanies  deep  tones  more   than 
others,  is  produced  by  the   transmission  of  the 
sound,   not  through    the   bronchial    tubes,   but 
through  the  common  substance  of  the  lung,  and 
is  so  slight  as  not  to   obscure  other  signs  to  any 
extent. 

Disease    may    produce  vocal     resonance  of 


PKCTORILOQUV.  55 

either  kind,  in  parts  where  it  does  not  naturally 
exist.  In  degree  equal  to  laryngophony,  this 
accidental  resonance  is  called  perfect  pecto- 
riloquy ;  and  when  it  simulates  the  natural 
resonance  under  the  sternum,  it  is  imperject  pec- 
toriloquy. 

These  symptoms  are  produced  by  unnatural 
cavities  in  the  substance  of  the  lung,  to  which 
the  sound  of  the  voice  is  propagated  through 
the  bronchi ;  and  their  presence  is  a  certain 
proof  of  the  existence  of  such  cavities.  When 
the  stethoscope  is  applied  to  a  part  of  the 
chest  under  which  lies  one  of  these  cavities,  the 
words  which  the  patient  utters  seem  to  proceed 
from  that  spot  ;  hence  the  term  pectoriloquy. 
The  distinction  between  perfect  and  imperfect 
pectoriloquy  is,  as  in  the  case  of  natural  reson- 
ance, whether  the  voice  seems  to  traverse  the 
tube,  or  to  remain  at  the  end  ;  and  the  physical 
difference  producing  the  two  modifications,  con- 
sists in  the  size  and  situation  of  the  cavity. 
The  most  perfect  pectoriloquy  is  produced  in 
cavities  of  moderate  size,  which  are  situated 
near  the  surface  of  the  lung,  and  freely  com- 
municate with  a  large  bronchial  tube.  If  the 
cavity  be  deep  seated,  or  if  its  communication 
with  the  bronchi  be  imperfect,  the  resonance  of 
the  voice  will  not  amount  to  perfect  pecto- 
riloquy.    True  pectoriloquy,  produced  by  a  ca- 


56  AUSCULTATION    OF   THE    VOICE. 

tity,  is  generally  .abruptly  circumscribed,  so 
that  its  limits  can  be  distinctly  traced. 

Pectoriloquy  may  be  considered  a  certain  in- 
dication of  a  cavity  (almost  always  tubercular,) 
whenever  occurring  in  those  parts  of  the  chest 
where  there  is  naturally  no  bronchial  reson- 
ance. When  it  is  heard  in  the  other  parts,  it  is 
more  doubtful,  but  even  there,  if  it  be  perfect, 
distinctly  circumscribed,  and  heard  so  on  one 
side  only,  it  leaves  very  little  room  for  doubt. 

There  is  another  way  in  which  the  vocal 
resonance  may  become  a  sign  of  disease.  As 
we  have  noticed  that  bronchial  respiration  may 
become  audible  by  the  condensation  of  the  in- 
tervening portion  of  vesicular  tissue;  so  the 
same  cause  may  transmit  to  the  surface  a 
bronchophony,  which  in  the  healthy  state  is 
confined  by  the  surrounding  ill-conducting 
tissue.  Hence  inflammation,  oedema,  tuber- 
cular and  sanguineous  infiltration  are  often  at- 
tended with  an  accidental  bronchophony-  Ac- 
cidental bronchophony  frequently  diners  from 
that  existing  naturally  in  certain  parts  of  the 
chest ;  but  of  this  difference,  and  of  that  called 
cegophony  I  shall  hereafter  speak. 

The  sputa,  in  pulmonary  diseases,  although 
the  signs  which  they  give  are  not  the  directly 
physical  effect  of  the  lesions,  yet  furnish  often 
such  certain   indications,  and    have  frequently 


EXPECTORATION-  57 

such  distinctive  characters,  that,  when  consulted 
together  with  the  physical  signs,  they  assist  in  a 
most  essential  manner  in  pointing  out  the  nature 
of  a  disease.     I   have,   therefore,  in  all   my  de- 
scriptions  of  the  pathology   and  signs,   referred 
to  the  character  of  the  secretion  of  the  bronchi, 
whenever  expectoration  presents  it  to  our  view. 
Such  is  the  general  view  that  I   would  give 
of  the  physical  signs  of  the  state   of  the  lungs  ; 
and   as  all   the    phenomena    noticed  have  been 
found   susceptible    of  explanation   according  to 
the  laws  of  acoustics,   we  shall    not  meet  with 
any  greater    difficulty     when  examining   them 
more  minutely  as  the  signs  of  particular  diseases. 
And  by    thus    studying  auscultation,  not  in  the 
manner  of  vague  and  unguided  experience,  la- 
borious to    acquire,  and  burthensome  to  recol- 
lect, but,   by  a  rational  examination  of  its   fun- 
damental principles,  and  an  application  of  these 
to  individual  cases,  the  student  will  be   enabled 
to    understand   as    well    as    know   the   physical 
signs   of  a  healthy  and   diseased    state,  and  to 
avail  himself  of  these  for  the  elucidation  of  dis- 
eases of  the  lungs,    and  for  the  suggestion   of 
means  for  their  cure. 

Section  II  J. — On  the  auscultation  of  the  Heart. 

The  signs  that  are   produced  by  the  action  of 
the  heart   I  have    found  neither  so   certain  in 

8 


58  AUSCULTATION    OF    THE    HEART. 

their  indications,  nor  so  intelligible  in  their  cau- 
ses as  those  which  I  have  hitherto  described  ; 
and  I  have,  therefore,  deemed  it  proper  to  post- 
pone any  attempt  to  include  them  within  the 
plan  of  this  work,  until  more  extensive  observa- 
tion and  study  shall  have  supplied  the  desired 
intelligence.  All  that  I  shall  at  present  intro- 
duce on  the  subject  is  a  short  exposition  of  a 
few  signs  which  experience  seems  to  have  proved 
to  be  unequivocal. 

The  sound  produced  by  muscular  contraction 
was  first  noticed  by  Dr.  Wollaston.  It  may  be 
exemplified  by  applying  the  palm  of  the  hand 
to  the  ear,  and  at  the  same  time  moving  the 
fingers.  There  is  then  heard  a  rumbling  sound, 
like  the  rolling  of  a  carriage  on  pavement,  ac- 
companied by  a  metallic  tinkling.  The  tinkling 
is  only  a  resonant  echo  produced  in  the  in- 
ternal meatus*  ;  it  is  the  rumbling  sound  that 
is  produced  by  the  contraction  of  the  muscles, 
and  is  the  same  that  in  different  degrees  ac- 
companies every  instance  of  regular  muscular 
action. 

Without  attempting  the  difficult  task  of  ex- 
plaining the  manner  in  which  sound  is  thus  ge- 
nerated, we  shall  here  content  ourselves  with 
the  fact.  It  occurs  in  the  contraction  of  the 
heart,   and  constitutes  the   sound  of  pulsation, 

*  See  the  Section  on  Pneumothorax. 


AUSCULTATION  OF  THE    HEART.  59 

which  is  heard  in  the  precordial  region.  This 
sound  is  double,  and  consists  of  a  dull,  slow 
noise,  immediately  followed  by  a  short  quick 
one,  to  which  succeeds  a  short  interval  of  si- 
lence. The  fir;>t  sound  is  produced  by  the  con- 
traction of  the  ventricles,  and  is  synchronous 
with  the  pulse  ;  the  second  is  caused  by  the 
contraction  of  the  auricles,  and  in  the  succeed- 
ing interval  both  are  at  rest.  Laennec  rates  the 
average  measure  of  these,  in  ordinary  pulsations 
to  be — the  contraction  of  the  ventricles  lasts 
two-fourths  ;  that  of  the  auricles,  one-fourth ; 
and  the  interval  of  rest  one-fourth  of  the  whole 
period  of  a  pulsation.* 

The  sound  of  pulsation  is  naturally  loudest  in 
the  praecordium,  that  is,  the  space  between  the 
cartilages  of  the  fourth  and  seventh  ribs  of  the 
left  side,  and  on  the  lower  part  of  the  sternum  ; 
the  former  part  corresponding  with  the  left,  and 
the  latter  with  the  right  side  of  the  heart.  In 
persons  of  middling  stoutness,  and  healthy  pro- 
portions, the  sound  scarcely  extends  beyond  this 
region  ;  in  very  fat  persons  it  is  still  more  limit- 
ed ;  but  in  thin  persons  the  pulsations  may  often 
be   heard  in  other  parts  of  the   chest  ;  ?nd  in 

*  Or,  noted  musically,  a  crochet,  a  quaver,  and  a  quaver  rest  in  a  bar. 
I  think  the  auricular  sound  bears  a  shorter  proportion  ;  and  we  shall  b« 
more  exact  if,  changing  the  measure,  we  note  it  a  dotted  crotchet,  a  qua- 
ver and  a  crotchet  reet. 


60  AUSCULTATION    OF    THE    HEART. 

these  cases  the  sound  will  diminish  in  the  fol- 
lowing order  of  parts  ;  the  left  side  from  the 
axilla  to  the  situation  of  the  stomach  ;  the  right 
anterior  and  lateral  regions  ;  the  left  posterior 
regions  ;  and  lastly,  where  it  is  rarely  heard,  the 
right  posterior  regions.  If  there  is  any  devia- 
tion from  this  order,  it  may  be  concluded  that 
there  is  either  something  unusual  about  the 
heart  producing  the  sound,  or  about  the  circum- 
jacent organs  transmitting  it. 

Besides  the  sound,  there  is  an  impulse  or 
shock  communicated  by  the  stethoscope  to  the 
ear  during  the  contraction  of  the  ventricles. 
This  impulse  is  felt  only  in  the  precordial  re- 
gion, and  if  the  sternum  be  short,  sometimes  in 
the  epigastrium. 

Such  are  the  common  phenomena  disco- 
vered by  auscultation  in  the  healthy  and  mo- 
derate action  of  the  heart.  The  following 
are  the  most  remarkable  effects  produced  by  dis- 
ease : 

Simple  dilatation  increases  the  loudness  and 
extent  of  the  pulsations,  but  diminishes  the  im- 
pulse that  accompanies  them.  Simple  hyper- 
trophy increases  the  impulse,  and  diminishes  the 
sound  of  the  pulsations.  Hypertrophy  and  di- 
latation equally  conjoined,  or  active  aneurism, 
increase  both  the  impulse  and  the  sound  in  de- 
gree and  in  extent ;    but  such  an   equal  com- 


AUSCULTATION    OF    THE     HEART.  61 

bination  seldom  exists,  and  the  prevailing  dis- 
ease is  generally  most  apparent  by  its  effects,  to 
which  some  of  the  others  may  be  superadded. 
Thus,  in  hypertrophy,  with  slight  dilatation,  the 
degree  and  extent  of  impulse  may  be  increased, 
whilst  the  sound  is  diminished  in  degree,  but 
more  diffused  in  extent,  &c.  If  any  of  these 
symptoms  are  heard  more  on  one  side  of  the 
praecordia  than  on  the  other,  it  is  to  be  con- 
cluded that  the  disease  lies  chiefly  in  that  side 
of  the  heart.  The  ventricles  are  the  most  usual 
seat  of  disease,  but  the  auricles  not  unfrequently 
suffer  also,  and  then  the  signs  of  derangement 
are  more  perceptible  in  the  upper  part  of  the 
precordial  region.  When  the  auricles  are  di- 
lated, their  sound  can  often  be  heard  as  well 
under  the  clavicles  as  in  the  praecordia.  A  va- 
riety of  irregularities  may  occur  in  the  rythm 
of  pulsation  of  the  different  parts  of  the  heart. 

Besides  the  sounds  produced  in  the  contrac- 
tion of  the  auricles  and  ventricles,  there  some- 
times occur  concomitant  sounds  of  a  peculiar 
kind  ;  apparently  produced  by  some  derange- 
ment in  the  action  of  the  heart  or  large  vessels. 
Such  are  the  murmur  follis,  murmur  limte,  pur- 
ring fremitus,  tyc.  These  are  not  only  heard 
in  the  region  of  the  heart,  but  sometimes  also 
along  the  course  of  large  arteries.  Laennec 
considered  them  to  be  of  the  nature   of  sounds 


62  AUSCULTATION    OF    THE    HEART. 

produced  by  muscular  contraction,  in  these 
cases  of  spasmodic  nature,  affecting  the  heart 
or  arteries  in  which  the  symptom  is  perceived. 
I  am  myself  disposed  to  think  that  were  we 
better  acquainted  with  the  laws  of  the  produc- 
tion of  sound,  we  might  find  that  it  may  be  ex- 
cited by  the  motion  of  liquids,  as  well  as*by  that 
of  air,  in  or  against  solids  of  a  particular  form  ; 
and  that  we  might  find  a  more  satisfactory  ex- 
planation of  the  phenomena  in  question  in  the 
moving  mass  of  blood  being  thrown  into  sonor- 
ous vibration  by  some  modification  in  its  course. 
Such  a  modification  might  be  produced  by  thick- 
ening or  irregularity  in  one  of  the  valves  of  the 
heart,  or  by  spasmodic  action  of  some  of  the  co- 
lumns carnese  ;  by  any  obstacle  in  the  calibre  of 
an  artery,  &c.  :  and  these  causes  might,  as  in  the 
analogous  case  of  air,  render  the  passage  of  the 
blood  sonorous,  instead  of,  as  it  usually  is,  silent. 

These  are  but  conjectures  ;  but  the  at- 
tempts of  others  to  explain  these  phenomena 
have  not  assumed  more  certain  form.  I  leave 
this  subject,  therefore,  having  introduced  it 
here,  only  because,  as  in  practical  auscultation, 
the  sounds  produced  by  the  heart  will  often,  al- 
though not  the  specific  object  of  examination, 
contrive  to  force  themselves  on  the  attention. 

Having  made  ourselves  acquainted  with  the 
general  acoustic  economy  of  the  chest,  we  have 


IMMEDIATE    AUSCULTATION.  63 

now  to  consider  the  manner  in  which  we  may 
practically  avail  ourselves  of  this  knowledge  in 
the  auscultation  of  particular  diseases. 

All  the  acoustic  phenomena  of  the  chest  may 
be  heard  by  the  simple  application  of  the  ear  to 
its  parietes.  Jn  this  immediate  method  of  auscul- 
tation, the  sound  is  communicated  through  the 
parietes  of  the  chest  to  the  air  in  the  hollow  of 
the  external  ear  and  meatus,  which  being  ex- 
cluded from  the  access  of  all  other  sounds,  re- 
ceives, in  unmodified  intensity,  every  vibration 
that  emanates  from  the  chest.  This  method  has 
the  advantage  of  being  simple,  expeditious,  and 
easily  acquired  ;  but  it  likewise  has  disadvan- 
tages, which  render  it  less  eligible  than  mediate 
auscultation.  The  direct  application  of  the  ear 
tojJie  chest  would  in  some  cases  be  indelicate, 
and  in  others  disgusting  ;  and  it  is  imprac- 
ticable in  some  parts,  as  the  axilla,  and  at  the 
junction  of  the  clavicle  and  humerus.  More- 
over, its  indications  are  more  equivocal  than 
those  obtained  by  the  stethoscope  ;  for,  besides 
extraneous  noises,  produced  by  the  friction  of 
the  hair  and  clothes,  sounds  of  neighbouring 
parts,  transmitted  by  the  mastoid  and  zygomatic 
projections  and  other  parts  of  the  side  of  the 
head,  in  contact  with  the  chest,  are  likewise 
sometimes  heard  in  a  confused  manner,  and 
obscure   the  immediate   object  of  examination 


64  MEDIATE    AUSCULTATION. 

These  objections,  which  Laennec  has  pointed 
out,  I  consider  of  sufficient  weight  to  authorize 
our  preference  of  the  stethoscope  in  general 
practice.  I  have,  nevertheless,  not  forsworn 
immediate  auscultation  ;  and  in  cases  requiring 
little  nicety  of  examination  I  often  avail  my- 
self of  the  greater  ease  and  celerity  of  this  me- 
thod, particularly  in  exploring  the  posterior 
parts  of  the  chest,  where  the  application  of 
the  stethoscope  requires  a  somewhat  tedious 
caution. 

The  stethoscope  is  an  acoustic  instrument 
employed  in  the  auscultation  of  the  chest.  Al- 
though its  construction  is  simple,  and  its  appli- 
cation easy,  yet  I  think  we  shall  lose  nothing 
by  giving  a  little  attention  to  analyze  its  physi- 
cal office,  and  render  intelligible  the  principles 
of  its  use.  When  we  bring  to  the  aid  of  our 
senses  artificial  instruments,  we  can  neither 
perfect  their  construction,  nor  fully  avail  our- 
selves of  their  application,  without  a  know- 
ledge of  the  physical  principles  on  which  they 
assist  our  organs.  No  one  can  make  a  proper 
use  of  the  microscope  or  telescope  without 
understanding  the  laws  of  optics  ;  and  I  hold 
that  the  easiest,  the  most  agreeable,  and  the 
most  certain  road  to  a  knowledge  of  stethoscopic 
phenomena,  is  through  a  study  of  acoustics. 
The  sounds  heard   by  auscultation  are  seve- 


THE  STETHOSCOPE.  65 

ral  in  nature  and  in  origin.  Those  of  the  voice 
and  respiration  are  produced  in  air  ;  that  is,  air 
is  the  vibrating  medium  ;  the  sounds  accompa- 
nying the  motions  of  the  heart,  on  the  other 
hand,  originate  in  a  solid  or  liquid.  This  cir- 
cumstance suggests  the  expediency  of  varying 
the  conductor,  according  to  the  principle  for- 
merly pointed  out,  that  a  sound  is  most  effec- 
tually transmitted  by  bodies  of  the  same  density 
as  that  in  which  it  is  produced.  Again,  some 
sounds,  as  that  of  respiration,  are  diffused  and 
weak,  and  by  concentration  may  be  made  more 
distinctly  audible  ;  while  others,  as  those  of  the 
voice,  are  produced  in  a  circumscribed  spot,  and 
are  loud  enough  in  themselves. 

Now  we  shall  find  that  all  these  differences 
may  be  met  by  a  little  modification  of  the  same 
instrument.  First,  let  us  take  a  solid  cylinder, 
which  shall  be  excellent  in  conducting  power, 
and  particularly  of  density  approaching  to  that 
of  the  contents  of  the  chest,  from  which  origi- 
nate the  sounds  to  be  conducted.  Nothing  will 
better  fulfil  this  end  than  wood,  of  light  sub- 
stance, but  with  considerable  rigidity  of  longi- 
tudinal fibre.  Deal,  which  on  account  of  a 
modification  of  the  same  property,  is  pre-emi- 
nently useful  in  the  construction  of  musical 
instruments,  most  completely  answers  to  this 
character ;  and  cedar  possesses,  in  addition,  the 
9 


66  THE    STETHOSCOPE. 

advantage  of  elegance.  With  a  solid  cylinder 
of  cedar,  then,  of  convenient  size,  say  ten  or 
twelve  inches  long,  and  one  inch  and  a  half  in 
diameter,  we  shall  best  be  enabled  to  hear  all 
those  sounds  that  originate  in  solids.  If  this 
cylinder  be  perforated  longitudinally  through 
the  centre,  by  a  hole  a  quarter  of  an  inch  in  dia- 
meter, this  central  canal  will  be  well  suited  to 
transmit  sounds  that  originate  in  air  in  circum- 
scribed spots.  To  concentrate  the  diffused 
sounds,  and  to  expedite  the  examination  by 
making  the  stethoscope  take  in  as  large  an  ex- 
tent of  surface  at  a  time  as  possible,  this  cy- 
linder is  hollowed  out  at  one  end  into  a  conical 
cavity,  the  apex  of  which  terminates  in  the 
central  canal ;  so  that  all  the  sounds  that  enter 
the  excavated  end  are  reflected  up  into  this 
canal,  which  conveys  them  to  the  ear.  To  re- 
convert this  into  a  simply  perforated  cylinder,  a 
perforated  plug  or  stopper  is  adapted,  of  size 
and  form  exactly  c  orresponding  with  the  coni- 
cal excavation.  Thus  contrived,  the  stethoscope 
is  adapted  to  transmit  sounds  to  the  ear,  either 
by  conduction,  along  the  fibres  of  the  wood,  or 
by  reflection,  through  the  central  canal. 

Such  are  the  general  principles  of  the  con- 
struction of  the  stethoscope  ;  for  more  particulars 
I  must  refer  to  the  plate  and  its  accompanying 
explanation. 


THE    STETHOSCOPE.  <57 

We  have  had  occasion  to  remark  that  aus- 
cultation with  the  stethoscope  requires  more 
practice  and  attention  than  auscultation  with 
the  naked  ear;  but  this  slight  addition  of  trou- 
ble will  be  more  than  repaid  by  the  greater  dis- 
tinctness and  certainty  of  its  indications.  It 
does  not  suffice  that  the  stethoscope  should  be 
resorted  to  only  where  delicacy  forbids  the  prac- 
tice of  immediate  auscultation  ;  for  it  will  be  of 
little  use  to  the  person  whose  ear  is  not  con- 
stantly accustomed  to  it.  By  using  the  stetho- 
scope habitually,  we  obtain  all  the  advantages 
of  universal  applicability  and  distinct  indica- 
tions, that  it  presents,  without  losing  those  of 
greater  ease  and  celerity,  which  if  particular 
instances  should  render  them  of  paramount  im- 
portance, are  still  open  to  us  in  immediate 
auscultation. 

A  little  well-regulated  practice  in  the  use  of 
the  stethoscope  is  worth  a  volume  of  directions 
and  cautions.  By  this  the  observing  student 
will  soon  find  how  necessary  it  is  to  keep  the 
instrument  closely  applied  both  to  the  chest  of 
the  patient  and  to  his  own  ear,  so  that  there  be 
no  communication  between  the  interior  of  the 
tube  and  the  external  air ;  to  hold  it  in  such  a 
manner,  by  the  end  near  the  chest,  that  no  ex- 
traneous sound  be  communicated  by  friction  of 
contiguous  clothes  or  otherwise  ;  to  avoid  pres- 


68  THE    STETHOSCOPE. 

sing  so  hard  upon  it  as  to  produce  pain,  or 
interfere  with  the  respiratory  movements ;  to 
avoid  too  stooping  or  constrained  a  posture, 
which  may  cause  tinnitus  aurium,  and  render 
hearing  obtuse ;  and  to  conduct  his  examina- 
tion of  the  series  of  signs  with  as  little  fatigue 
to  the  patient  as  the  case  will  permit. 

The  patient  should  not  have  over  the  chest 
more  than  a  single  garment  of  linen  or  cotton, 
and  this  should  be  kept  smooth  under  the  in- 
strument. To  explore  the  anterior  and  lateral 
regions  the  patient  may  be  either  seated  on  a 
chair,  or  lying  near  the  edge  of  a  bed :  the 
examination  of  the  back  must  be  effected  in  the 
sitting  posture  with  the  body  bent  forwards. 
It  is  always  the  best  plan  to  change  sides  in 
order  to  examine  the  opposite  side  of  the  chest, 
and  not  lean  across,  unless  it  be  for  the  compa- 
rison of  corresponding  points  on  both  sides, 
where  it  is  important  that  the  two  impressions 
should  succeed  quickly  to  each  other.  The 
attentive  student  will  soon  find  how  far  these 
precautions  are  necessary  ;  and  to  what  degree 
tact,  furnished  by  experience,  may  supersede 
or  modify  them. 

It  is  generally  expedient  to  follow  a  particular 
order  or  method  in  conducting  a  physical  exami- 
nation of  the  chest.  I  usually  begin  with  per- 
cussion, first  on  the  clavicles,  then  on  the  ante- 


EXAMINATION  OF  PHYSICAL  SIGNS.  69 

rior  parts  of  the  chest,  proceeding  from  above 
downwards ;  next  on  the  lateral  portions,  begin- 
ning at  the  axilla,  which  are  exposed  by  the  pa- 
tient raising  his  arm  up  to  his  head.  The  same 
parts  are  then  examined,  in  like  order,  by  the 
stethoscope,  with  due  attention  to  the  indications 
just  obtained  by  percussion.  For  the  percus- 
sion of  the  posterior  part  of  th  e  chest,  the  pa- 
tient must  sit  with  his  head  bowed  forwards, 
and  his  arms  crossed  over  his  breast ;  and  after 
due  care  in  exercising  percussion  in  this  more 
obscure  region,  the  easier  test  of  auscultation 
may  be  practised. 

For  exploring  the  respiration,  cough,  and 
most  of  the  rhonchi,  the  stethoscope  should  be 
used  without  its  stopper.  The  signs  of  the 
voice  are  least  equivocal,  when  heard  with  the 
stopper  in,  and  to  .determine  the  extent  of 
a  rhonchus  cavernosus,  or  crepitans,  or  of  a 
bronchial  respiration,  it  is  often  useful  to  resort 
to  the  instrument  in  this  form.  The  heart  is 
examined  in  the  same  manner  ;  but  when  it  is 
wished  to  hear  the  sound  of  pulsation  without 
the  impulse,  the  stopper  should  be  taken  out. 

The  physical  examination  of  the  chest,  when 
adroitly  and  systematically  conducted,  is  not 
nearly  so  tedious  as  might  be  imagined,  and  it 
is  surprising  with  what  ease  and  expedition  it 
may  be   performed  after  some  experience.     A 


70  EXAMINATION   OF    PHYSICAL    SIGNS. 

few  minutes  will,  in  a  majority  of  cases,  suffice 
to  furnish  us  with  information  far  more  certain 
than  can  be  obtained  in  any  other  way  ;  and,  in 
cases  of  obscurity  and  difficulty,  a  much  longer 
time  devoted  to  it  should  not  be  considered  as 
thrown  away.  But  in  all  cases  time  should  be 
deemed  of  much  lower  value  than  a  true  know- 
ledge of  the  disease  ;  and  I  hold  it  to  be  the 
duty  of  the  conscientious  physician  to  consider 
this,  and  the  employment  of  curative  measures 
founded  upon  it,  as  the  paramount  objects  of 
his  care, 

"  Prudens  interrogatio  dimidium  est  sci- 
entise  ;"  and  if  its  application  to  medicine  does 
not,  at  the  outset,  always  obtain  the  desired 
end,  it  is  only  through  its  means  that  we  can 
hope  to  place  medicine  on  a  footing  with  other 
sciences,  and  render  the  art  in  any  degree  cer- 
tain and  effective. 


PART  II. 


OF   THE    PHYSICAL    SIGNS    OF    DISEASES    OF    THE 
LUNGS    AND   PLEURA. 

Hitherto  we  have  considered  physical  signs 
only  with  relation  to  the  natural,  or  physical 
state,  and  the  general  pathology  of  the  lungs  ;  it 
now  becomes  our  task  to  study  the  forms  or 
characters  that  individual  diseases  present  to  the 
auscultator.  To  understand  the  physical  signs 
of  a  disease,  it  is  quite  obvious  that  we  must  be 
acquainted  with  its  pathological  characters  ;  for 
they  are  naturally  inseparable :  and  I  view  it 
as  not  among  the  least  advantages  of  phy- 
sical examination,  that  it  directs  our  attention 
through  a  confusing  crowd  of  uncertain  and 
equivocal  symptoms  of  general  derangement,  to 
that  substantial  and  primary  lesion,  which,  if 
not  the  starting  point  of  all,  is  that  against  which 
our  practical  efforts  are  the  most  required. 

My  object  will  be,  not  to  enter  into  minute 
details  of  pathology  and  morbid  anatomy  ;  but 
as  far  as  my  own  observations  and  those  of 
others  will  enable  me,  to  explain  the  general  phy- 
sical nature  of  the  changes  which,  in  individual 


72  ACUTE    BRONCHITIS. 

diseases,  modify  the  acoustic  relations  of  the 
lungs  and  pleura.  I  shall  generally  confine  the 
text  to  pathology,  properly  so  called,  but  I  shall 
not  omit  to  append,  in  form  of  notes,  a  descrip- 
tion of  the  general  morbid  appearances  found 
after  death,  by  a  comparison  of  which  with  the 
physical  signs  during  life,  the  real  nature  of  a 
disease  is  to  be  known.  I  begin  with  the  dis- 
eases affecting  the  air  tubes  of  the  lungs. 

CHAP.  I.    Section   I.— Bronchitis. 

The  pathological  cause  of  bronchitis,  or  pul- 
monary catarrh,  is  an  inflammation  and  alter- 
ed secretion  of  the  mucous  membrane  of  the 
bronchia.  There  are  several  varieties,  and,  per- 
haps, even  species  of  this  disease  ;  but  as  they 
pass  insensibly  into  each  other,  and  as  the  phy- 
sical signs  of  all  are  frequently  combined  in  one, 
I  shall  comprehend  in  this  section  their  general 
description. 

Inflammation  of  the  mucous  membrane  of  the 
bronchi  at  first  causes  tumefaction  and  partial 
obstruction  of  their  calibre.  This  partial  ob- 
struction, or  constriction,  when  it  occurs  in 
individual  points,  modifies  the  passage  of  air 
through  the  bronchial  tubes,  and,  producing 
vibrations,  converts  these  tubes  into  instruments 
of  music.  If  the  whole  periphery  of  a  portion 
of  a  tube  be   tumified,  the  constriction   is  cir- 


PATHOLOGY    AND    SIGNS.  73 

cular,  and  the  air  passing  through  it  produces  a 
whistling  sound.  This  constitutes  the  rhonchus 
sabilans.  If  the  tumefaction  be  unequal,  so  that 
the  constricted  portion  preserves  a  flattened 
aperture,  then  a  sound  is  produced  after  the 
manner  of  reed  instruments,  or,  rather,  of  the 
horn  or  trumpet,  by  the  rapid  alternate  com- 
pression and  dilatation  of  the  air  passing  be- 
tween two  vibrating  lamina?,  or  surfaces.  Such, 
I  conceive,  is  the  rationale  of  the  rhonchus 
sonorus.  The  extent  of  the  constriction,  its 
situation,  and  the  secretion  lubricating  the  tube, 
will  variously  modify  the  note  and  tone. 
The  larger  bronchial  tubes  alone  can  produce 
deep  or  bass  notes  ;  but  it  is  plain  that  they  may 
also  yield  high  ones.  When  a  deep  rhonchus 
sonorus  is  produced  in  a  bronchus  near  the  sur- 
face of  the  lung,  it  communicates  a  slight  vibra- 
tion to  the  corresponding  paries  of  the  thorax, 
which  maj'  be  felt  by  the  hand.  This  mecha- 
nical vibration  is  often  perceived  internally  by 
the  patient  himself,  although  he  does  not  hear 
the  sound  that  produces  it. 

The  sonorous  and  sibilant  rhonchi,  then,  we 
find  to  be  the  first  physical  signs  of  pulmonary 
catarrh,  and  these  are  sometimes  present  be- 
fore the  cough  becomes  pronounced,  and  while 
the  general  symptoms  only  indicate  a  nasal 
coryza.  As  the  inflammation  attacks  .the  larger 
10 


74  ACUTE    BRONCHITIS. 

bronchial  ramifications  first,  the  rhonchus  is 
usually  grave,  and  frequently  resembles  the  pro- 
longed note  of  a  violoncello,  and  sometimes  the 
cooing  of  a  dove. 

After  a  while  the  inflamed  membrane  begins 
to  secrete  a  thinnish  saline  tasted  liquid,  which 
at  first  mellows  the  sound  of  the  rhonchi,  but 
afterwards  increasing,  interrupts  it  by  the  for- 
mation of  a  bubble,  which  momentarily  stops  the 
vibrations,  and  then  bursts.  These  bubbles 
increase  in  number  as  the  secretion  increases, 
and  are  at  last  produced  in  such  a  continuous 
succession,  that  the  sound  of  the  former  rhonchi 
ceases,  and  is  replaced  by  a  new  one  produced 
by  the  successive  formation  and  rupture  of 
bubbles  in  the  air  tubes.  This  is  the  mucous  or 
bubbling  rhonchus.  In  the  larger  bronchi  the 
mucous  rhonchus  is  composed  of  bubbles  of  un- 
equal size,  causing  a  gurgling  sound  ;  but  in 
the  smaller  tubes  the  bubbles  are  more  uni- 
formly small,  and  the  rhonchus  may  be  called 
finer  :  they  are,  still,  however,  somewhat  un- 
equal ;  and  even  when  in  the  extreme  bronchi 
they  can  be  distinguished  to  be  liquid  bubbles, 
and  quite  different  from  the  uniform  dry  cre- 
pitation that  constitutes  the  rhonchus  cre- 
pitans. J  have  been  minute  in  this  descrip- 
tion, because  the  distinction  is  important,  as 
on  it  depends  the  diagnosis   between  an  acute 


PATHOLOGY    A  XI)    SIGNS.  75 

pulmonary  catarrh,  and  the  first  stage  of  pneu- 
monia*. 

The  next  modification  in  the  rhonchus  is  pro- 
duced by  the  thickening  of  the  mucus  con- 
tained in  the  air  passages.  This  change,  which 
usually  diminishes  the  severity  of  the  cough,  is 
marked  by  the  mucous  rhonchus  becoming  drier 
and  more  sluggish,  from  the  resistance  opposed 
to  the  air  in  passing  through  the  inspissated 
liquid.  This  resistance  increases  with  the  in- 
creasing spissitude  of  the  mucus,  and  some- 
times amounts  to  a  complete  obstruction  of  the 
tube  ;  and  in  this  case  the  sound  of  respiration 
ceases  in  the  part  supplied  by  it.  More  fre- 
quently, as  the  mucus  becomes  thick,  its  quan- 
tity is  diminished,  and  then  it  only  partially 
obstructs    the  tube.      This    straitening   of   the 

*  An  ignorance  of  this  distinction,  and  of  the  elements  of  the  rhonchus 
crepitans,  seems  to  have  given  rise  to  M.  Andral's  assertion,  (Clin.  Med. 
t.  ii.)  that  this  rhonchus  may  be  produced  by  a  simple  acute  bronchitis  ; 
an  opinion,  as  M.  Laennec  remarks,  supported  by  no  observation  ;  and, 
I  may  add,  perhaps  attributable  to  his  having  neglected  the  efficient  clini- 
cal instructions  of  the  great  inventor  of  auscultation.  Let  not  this  expres- 
sion of  opinion  be  construed  into  a  want  of  deference  towards  M.  AndraL 
I  have  been  witness  of  the  devoted  zeal  of  this  able  pathologist,  I  have 
watched  his  labours,  and  let  me  add,  with  sentiments  of  real  gratitude,  1 
have  profited  by  his  instructions  ;  and  were  I  required  to  name  a  maa 
whose  indefatigable  industry  is  worthy  of  imitation,  whose  talented  mind 
commands  admiration,  while  his  amiable  deportment  ensures  esteem,  and 
to  the  fruit  of  whose  labour  we  may  look  for  the  advancement  of  medical 
science — the  name  of  Andral  would  gladly  be  brought  to  my  lips. 


76  ACUTE    BRONCHITIS. 

calibre  may  cause  a  rhonchus,  and  being  soft 
and  incapable  of  vibration  itself,  the  sound  pro- 
duced is  a  whistle,  in  which  air  is  the  only  vi- 
brating body.  Occasionally,  however,  at  this 
period  of  the  catarrh  a  ticking  sound  is  heard, 
like  that  produced  by  the  click  wheel  of  a  small 
clock.  This  is  caused  by  a  pellet  of  thick 
mucus  at  the  orifice  of  a  bronchial  ramification, 
which  acts  like  a  loose  valve,  yielding,  in  suc- 
cessive jerks,  to  the  air  pressing  for  passage.  A 
change  in  the  force  of  respiration  may  much 
modify  these  several  sounds.  Thus,  the  for- 
cible expiration  and  inspiration  accompanying 
a  cough  may  produce  the  clicking  sound,  or 
even  the  rhonchus  sibilans,  in  a  tube  which,  in 
ordinary  respiration,  is  totally  obstructed  with 
mucus ;  it  may  convert  the  clicking  into  sibila- 
tion,  and  this  into  the  simple  sound  of  the 
passage  of  the  air  ;  the  obstacles  yielding,  in  all 
these  cases,  to  the  increased  force  of  the  pass- 
ing air.  It  is  therefore  useful  to  avail  ourselves 
of  this  simple  mode  in  our  examination  ;  for,  on 
desiring  the  patient  to  cough,  the  nature  of  the 
obstruction  may  frequently  be  made  apparent 
by  the  momentary  presence  of  one  of  the  above 
signs. 

The  uncertainty  in  which  the  signs  of  auscul- 
tation sometimes  leave  us  is  completely  removed 
by  percussion.     The  sonorousness  of  the  chest 


PROGNOSIS.  77 

is  never  sensibly  impaired  by  catarrh  ;  and, 
accordingly,  the  partial  suspension  of  the  re- 
spiration in  a  part  of  the  chest,  in  this  disease, 
cannot  be  erroneously  ascribed  to  hepatization, 
or  an  effusion  in  the  pleura. 

The  extent,  as  well  as  the  seat  of  the  catarrh, 
may  be  determined  by  the  rhonchi.  These 
are  usually  confined  to  a  portion  of  one  lung, 
and  the  disease  is  not  dangerous  ;  but  if  they 
occupy  a  large  extent  of  both  lungs,  there  may 
be  considerable  danger,  the  fever  and  dyspnoea 
being  very  great.  Cases  of  this  kind  proving 
fatal,  are,  in  this  country,  erroneously  consider- 
ed peripneumonic.  In  some  cases  of  continued 
fever  the  rhonchi  indicate  a  catarrh  in  every 
part  of  the  lungs  :  they  are  the  sibilant,  sono- 
rous, and  mucous  rhonchi ;  and  when  thus  mix- 
ed, Laennec  used  to  designate  them  rhonchus 
canorics.  Their  presence  may  be  considered  a 
very  unfavourable  sign,  and  is  seldom  indicated 
by  the  cough  or  other  symptoms,  being,  as  it 
were,  masked  by  the  general  affection  of  the 
system.  In  general,  an  acute  catarrh  is  more 
dangerous  in  proportion  to  the  age  of  the  pa- 
tient, and  this  probably  depends  on  the  differ- 
ent capability  of  dilatation  in  the  pulmonary 
tissue  ;  being  greater  in  young  subjects,  it  per- 
mits supplementary  respiration  in  the  healthy 
parts  to  supply  the  defect  of  the  diseases.     Be- 


78  CHRONIC    BRONCHITIS. 

sides  these,  as  in  all  diseases  obstructing  the 
respiratory  function,  the  dyspnoea  (and  hence 
the  danger,)  will  be  great  in  proportion  as  this 
function  is  naturally  or  constitutionally  active 
in  the  individual. 

If  the  catarrh  terminates  in  cure,  the  expec- 
toration becomes  thicker,  and  more  concocted, 
as  the  ancients  termed  it.  It  is  voided  without 
irritation,  in  rounded,  distinct  pellets,  consist- 
ing of  an  opake,  greenish  mucus.  These  and 
the  cough  diminish,  and  are  confined  to  the 
morning,  after  waking,  and  a  few  times  in  the 
evening,  and  at  last  cease  altogether. 

But,  if  neglected,  the  catarrh  may  assume  a 
chronic  form.  The  cough  and  expectoration 
then  continuing,  the  latter  is  usually  at  first  of 
the  same  quality  as  at  the  termination  of  the 
acute  stage,  but  it  sometimes  becomes  diffluent, 
less  viscid,  and  of  a  dirty  brownish  colour.  After 
a  while,  it  frequently  is  mixed  with  pus,  and 
sometimes  becomes  completely  purulent,  pre- 
senting all  varieties  in  odour  and  consistence 
that  pus,  from  other  sources,  offers.  To  these 
are  sometimes  added  shortness  of  breath,  hectic 
fever,  night  sweats,  emaciation,  and,  in  short, 
all  the  rational  symptoms  of  phthisis. 

Deprived,  as  we  are,  of  the  means  of  diag- 
nosis by  these  fallacious  signs,  let  us  endeavour 
to  supply  the  defect   by  appealing  to  the  phy- 


PHYSICAL  SIGNS,  79 

sical  indications.  And  here  let  me  caution  the 
young  auscultator  against  too  perfect  a  confi- 
dence in  his  examinations,  and  too  hasty  a  con- 
clusion from  their  results.  As  the  diagnosis  is 
important,  so  is  it  often  difficult. 

The  symptoms  heard  by  the  ear  in  chronic 
catarrh,  are  the  mucous  rhonchus,  in  most  of 
its  varieties,  shifting  and  intermitting  from  time 
to  time,  and,  occasionally  the  sibilant,  the  pre- 
sence of  which  is  explained  by  the  sputa  ;  the 
sound  of  respiration,  sometimes  diminished,  but 
usually  unimpaired,  or  even  puerile*;  and  the 
chest,  on  percussion,  yields  a  clear  sound.  It 
will  be  perceived  that  all  these  signs  are  n  ega- 
tive,  and  none  of  them  characteristic  of  this  mo- 
dification of  catarrh.  It  is  therefore  in  the  ab- 
sence of  the  signs  hereafter  to  be  described,  as 

*  The  presence  of  the  dyspnoea,  in  these  cases,  where  there  is  no  ob- 
stacle to  the  entrance  of  air  into  the  lungs,  nay,  where  the  puerile  res- 
piration shews  it  to  be  more  perfect  than  usual,  is  ascribed  by  Laennec  to 
an  increased  "  besoin  de  respirer."  In  the  present  instance,  however,  I  see 
nothing  more  in  this  explanation  than  an  expression  of  the  fact.  There 
is  nothing  in  the  state  of  the  system  that  indicates  the  want  of  an  increased 
activity  in  the  respiratory  function.  The  quantity  and  quality  of  the  urine, 
and  the  other  excretions,  may  be  taken  as  pretty  correct  criteria  of  the 
extent  of  the  chemical  changes  by  respiration.  1  think,  that  we  must  look 
rather  to  the  change  in  the  nature  of  the  bronchial  mucus  for  an  explana- 
tion of  the  point  in  question.  I  have  elsewhere  (Trans,  of  Med.  Chir.  Soc. 
ofEdin.,  vol.  ii.  p.  100.)  pointed  out  an  important  part  which  this  mucus 
performs  in  assisting  the  action  of  the  air  on  the  blood.  It  is  easy  to  con- 
ceive how  a  diseased  state  may  unfit  it  for  this  office,  and  impair  the  chem- 
ical function  of  respiration,  however  perfectly  the  mechanical  part  be  per- 
formed. 


80  CHRONIC    BRONCHITIS. 

peculiar  to  phthisis,  that  we  must  recognise  the 
character  of  chronic  catarrh.  As,  however,  ne- 
gative are  weaker  than  positive  proofs,  so  must 
they  be  multiplied  to  be  rendered  certain.  Jf, 
after  having  repeatedly  examined  the  patient, 
at  different  hours  during  several  weeks,  there 
are  found  no  gurgling  cavernous  rhonchus, 
no  cavernous  respiration,  no  pectoriloquy,  and 
no  constant  absence  of  the  respiratory  murmur, 
and  of  the  sound  on  percussion,  then,  in  spite  of 
the  general  symptoms,  we  may,  with  tolerable 
certitude,  pronounce  the  disease  to  be  simply 
pulmonary  catarrh,  and  a  still  further  multipli- 
cation of  examinations  will  remove  all  doubt*. 

The  long  continuance  of  chronic  catarrh  may 
entail  an  organic  change  in  the  lung,  which  will 
almost  destroy  all  distinction  between  its  signs 
and  those  of  tubercular  phthisis.  The  bronchi, 
long  the  seat  of  chronic  inflammation,  and  ex- 
posed to  the  straining  influence  of  repeated 
paroxysms  of  cough,  become  hypertrophied  and 
dilated. 

I  offer  this  explanation  in  preference  to  the 

*  This  passage  I  have  given  nearly  in  the  words  of  the  illustrious  dis- 
coverer of  auscultation  ;  yet,  aware  as  he  was  of  the  attention  required  in 
the  examination,  and  of  the  falibility  of  a  hasty  judgment,  I  have  more  than 
once  seen  himself  give  proof  in  point  by  the  failure  of  a  premature  diagno- 
sis. If  then,  one,  from  knowledge  and  experience  so  profoundly  acquainted 
with  his  subject,  was  through  inadvertency,  led  into  error,  how  much 
more  circumspect  should  they  be  who  have  not  his  experienced  tact,  and 
his  talent  for  improving  observation. 


DILATED    BRONCHI.  81 

opinion  of  Laennec,  that  the  bronchi  are  dilated 
by  the  accumulation  of  a  thick  mucus  in  them, 
for  this  reason— that  the  sign  of  such  accumula- 
tion, namely,  a  suspension  of  the  sound  of  re- 
spiration in  the  part  is  scarcely  ever  observed 
in  chronic  catarrh  ;  nay,  the  absence  of  this  sign 
serves  to  distinguish  the  chronic  from  the  acute 
disease.  The  dilatations  are  produced,  I  ap- 
prehend, in  this  manner:  in  the  forcible  expi- 
ration of  coughing,  the  exit  of  the  air  is  par- 
tially impeded  by  a  coarctation  of  their  calibre  ; 
the  air  thus  confined,  therefore,  sustains  the 
partial  pressure  of  the  respiratory  forces,  and 
in  its  turn  presses  the  yielding  parietes  of  the 
bronchi  against  those  portions  of  the  surround- 
ing pulmonary  tissue  in  which  there  is  no  ob- 
struction to  the  exit.  This  pressure,  frequently 
repeated  on  membranes  already  modified  by 
disease,  ends  in  producing  a  permanent  dilata- 
tion. In  accordance  with  this  explanation, 
these  dilatations  are  chiefly  produced  where  the 
fits  of  coughing  are  very  violent  and  convulsive, 
as  in  pertussis  and  catarrhus  senilis. 

These  dilatations,  at  different  points  in  the 
course  of  the  tubes,  form  cavities  of  various 
sizes,  still  lined  with  the  mucous  membrane, 
which  can  be  traced  from  the  undilated  portions 
of  the  tubes.  It  can  be  easily  conceived  how 
^hese  cavities  may  give  riste  to  pectoriloquy, 
11 


82  CHRONIC    BRONCHITIS. 

cavernous  respiration,  and  most  of  the  other 
phenomena  by  which  a  cavity  from  tuber- 
cular excavation  is  distinguished.  The  diag- 
nosis is,  perhaps,  in  these  cases,  of  less  import- 
ance, as  art  has  little  power  over  either  form  of 
organic  disease  :  but,  when  on  the  subject  of 
phthisis,  I  will  endeavour  to  point  out  some 
means  of  discrimination,  available  at  least  to 
the  experienced  stethoscopist. 

Dilatation  of  the  bronchi,  when  extensive, 
may  produce  habitual  dyspnoea,  by  obliterating 
portions  of  the  pulmonary  texture. 

Section  II. — Pituitary  Catarrh. 

The  varieties  of  catarrh,  which  Laennec  terms 
from  the  nature  of  the  expectoration,  pituitary 
and  dry  catarrh,  require  to  be  noticed  as  far 
as  they  differ  in  their  physical  signs  from  mucous 
catarrhs. 

In  the  pituitary  catarrh,  or  humoral  asthma, 
as  some  of  our  own  practitioners  have  termed 
it,  a  thin,  colourless,  glary  liquid,  is  secreted  in 
abundance  by  the  bronchial  membrane.  This 
flux  comes  on  in  paroxysms,  attended  with 
dyspnoea  and  cough,  which  are  relieved  by  the 
expectoration  of  the  liquid.  It  does  not  appear 
that  the  membrane  becomes  much  tumified, 
unless  occasionally  by  the  co-existence  of  a  slight 
degree  of    oedema.     The  dyspnoea   and   cough 


PITUITARY   CATARRH.  83 

are  therefore  to  be  ascribed  to  the  quantity  of 
fictitious  secretion. 

The  respiratory  murmur  is  weak,  accom- 
panied with  the  sonorous  and  sibilant  rhonchi, 
occasionally  modified  by  bubbles  of  the  mucus, 
so  as  to  imitate  the  chirrupping  of  birds,  and 
sometimes  heard  distinctly  with  a  liquid  mucous 
rhonchus.  When  a  slight  oedema  is  present  the 
humid  crepitant  rhonchus  may  also  be  distin- 
guished, but  this  disappears  in  the  interval 
with  the  other  signs.  The  chest,  on  percussion, 
sounds  well  throughout  the  attack. 

This  catarrh  may  be  confined  to  one  or  two 
paroxysms,  or  it  may  attack  daily  for  months 
and  even  years.  Like  most  other  serous  fluxes, 
it  is  very  difficult  to  remove  when  once  esta- 
blished, and  frequently  arises  from  the  develop- 
ment of  a  number  of  military  tubercles  in  the 
pulmonary  tissue.  Its  long  continuance  pro- 
duces that  change  in  the  mucous  membrane 
that  commonly  accompanies,  or  is  produced  by, 
profuse  watery  discharges.  This  is  a  degree 
of  atrophy  which  is  sometimes  attended  with 
perfect  pallidity,  and  sometimes  with  irregular 
striae  or  patches  of  sanguineous  injection. 

From  what  I  have  seen  of  these  cases,  I  am 
disposed  to  consider  the  prevailing  evil  to 
be  a  debility  or  want  of  tone  in  the  vessels  of 
the  bronchial  membranes,  on  account   of  which 


84  DRY    CATARRH. 

the  watery  parts  of  the  blood  transude  with 
little  restraint  and  little  modification.  Inflam- 
mation may  have  been  in  the  first  instance  the 
cause  of  this  loss  of  tone  in  the  vascular  fibre ; 
and  even  although  it  does  not  afterwards  con- 
tinue, phlogistic  agents  may  aggravate  the 
disease,  by  increasing  the  force  of  the  circula- 
tion, by  which  a  flow  of  liquid  becomes  directed 
to  the  weakenedpart. 

Section  111.— Dry  Catarrh, 

The  dry  catarrh  of  Laennec  is,  perhaps,  in 
its  general  signs,  more  allied  to  asthma  than  to 
the  preceding  diseases.  It  consists  in  a  san- 
guineous congestion  in  the  membrane  of  the 
bronchi,  which  causes  tumefaction,  and  partial 
or  complete  obstruction  in  their  calibre.  There 
is  with  this  a  scanty  secretion  of  thick,  semi- 
transparent,  ash-coloured  mucus,  which  arranges 
itself  in  globules,  completing  the  obstruction  of 
the  tube. 

The  stethoscopic  sign  of  this  affection  is, 
accordingly,  a  suspension  of  the  sound  of  respi- 
ration in  the  part  affected,  while  the  corres- 
ponding part  of  the  chest  sounds  perfectly 
well.  Sometimes  the  obstruction  is  not  quite 
complete,  and  then  there  may  be  a  slight  sibi- 
lant or  a  clicking  rhonchus. 

The  severity  of  this  affection  depends  entire- 


PATHOLOGY    AND    SIGNS.  85 

]y  on  its  extent,  and  this  may  vary  from  a  degree 
not  at  all  deranging  the  general  health  to  one 
producing  severe  and  oppressive  asthma.  Many 
persons,  appafently  in  perfect  health,  only 
perhaps  subject  to  some  shortness  of  breath  on 
exertion,  present  to  the  auscultator  examples 
of  the  slightest  degree,  and  these  usually  ex- 
pectorate every  morning  a  small  portion  of  the 
pearly  mucus  that  I  have  described.  If  the  en- 
gorgement affect  a  longer  extent  of  the  bronchi, 
some  degree  of  dyspnoea  may  be  felt  even  when 
the  person  is  at  rest,  particularly  after  meals. 
In  a  severer  case  the  dyspnoea  may  last  for  sev- 
eral days,  and  is  usually  relieved  by  cough  and 
expectoration  of  a  small  quantity  of  the  same 
viscid  mucus.  These  symptoms  are  still  in  pro- 
portion to  the  extent  of  suppression  and  ob- 
struction of  respiration  observed  by  ausculta- 
tion. 

This  disease  not  unfrequently  terminates  in 
the  pituitary  form ;  or  rather,  its  paroxysms 
sometimes  end  in  a  watery  expectoration,  with 
a  small  proportion  of  the  tough  mucus  in  it. 
Like  pituitary  catarrh,  it  may  have  its  first 
origin  in  an  inflamed  state  of  the  mucous 
membrane  ;  but  from  the  natural  duration  of 
the  symptoms,  as  well  as  from  the  appearance 
after  death,  I  am  disposed  to  consider  its 
present  cause   rather  as  a  passive  congestion, 


86  PERTUSSIS. 

and  consequently  interrupted  secretion,  arising, 
perhaps,  from  deranged  nervous  influence,  than 
an  active  inflammation. 

Section  IV. — Pertussis,  Croup,  fyc. 

The  physical  signs  of  pertusis  do  not  ma- 
terially differ  from  those  of  common  catarrh, 
and  are  usually  slight.  In  the  intervals  of  cough, 
the  respiratory  murmur  becomes  indistinct  in 
some  points,  and  puerile  in  others  ;  a  sibilant 
or  sonorous  rhonchus  is  sometimes  heard,  and 
the  sound  of  the  chest,  on  percussion,  is  un- 
impaired. From  this  it  may  be  concluded,  that 
the  violence  of  the  cough  does  not  depend  en- 
tirely on  the  state  of  the  mucous  membrane  of 
the  air-passages,  and  an  examination,  during  a 
fit  of  coughing,  confirms  this  conclusion.  If  the 
ear  is  applied  to  the  chest  at  this  period,  no 
rhonchus  or  respiratory  sound  is  heard,  except 
for  a  moment,  between  each  cough ;  and  during 
the  sonorous  back-draught  all  is  silent  within  the 
chest.  This  absence  of  the  respiratory  sound,  in 
an  inspiration  that  seems  so  deep  and  forcible,  is 
to  be  attributed  to  the  admission  of  air  being 
slow  and  scanty,  on  account  of  the  spasmodic 
constriction  of  the  glottis,  by  which,  too,  the 
hooping  noise  is  caused.  A  spasm  of  the  mus- 
cular fibres  of  the  whole  bronchial  tract  may 
also  contribute  to  the  exclusion  of  air  from  the 


croup.  87 

air-cells,   but  I  cannot,  with  Laennec,  consider 
this  as  the  only  cause. 

I  have  had  no  opportunity  of  exploring  the 
signs  of  croup,  nor  is  it  easy  to  predicate  what 
they  would  be.  Laennec  gives  a  solitary  exam- 
ple of  a  bronchial  croup,  in  which  the  presence 
of  an  adventitious  membrane  caused  a  dry  and 
tubular  respiration,  without  the  diffused  slightly 
crepitant  sound  so  marked  in  children.  This, 
with  the  sound  of  percussion  unimpaired,  if 
found  constant,  would  (he  suggests)  be  suffi- 
ciently distinctive  of  this  form  of  the  disease. 
The  clearest  physical  sign  of  inflammatory  tra- 
cheal croup  is,  certainly,  the  detachment  and 
expectoration  of  the  factitious  membrane  that  is 
formed  in  the  air-passages.  But  I  have  little 
doubt  that,  by  attentive  observation,  a  diagnosis 
might  be  drawn  from  the  difference  in  the  sound 
of  the  voice,  and  passage  of  the  air  through 
the  trachea,  and  even  from  percussion  upon  it. 
Nor  would  it  be  unworthy  of  the  inquiry  :  for 
the  distinction  between  croups  produced  by  a 
false  membrane,  by  spasmodic  contraction,  by 
oedema  of  the  glottis,  by  the  pressure  of  an  ab- 
scess, and  other  causes,  involves  important 
points  in  practice,  a  knowledge  of  which  might 
have  prevented  many  fatal  accidents.  A  care- 
ful observer,  having  a  knowledge  of  the  laws 
of  sound  for  a  guide,  might,  by  attention  to  this 


88  ULCERS,  &C.  IN    THE    BRONCHI. 

subject,  confer  an  important  service  on  the  heal- 
ing art. 

I  do  not  believe  that  ulcers  of  the  bronchi 
have  any  constant  sign  by  which  they  can  be  dis- 
tinguished. They  excite  a  copious  mucous  se- 
cretion from  the  membrane,  which  is  sometimes 
mixed  with  pus  and  blood.  The  presence  of  the 
same  liquids  in  the  bronchi  occasions  a  mucous 
rhonchus.  In  these  cases  the  local  pain,  excited 
particularly  by  exertions  of  the  voice,  is  the  most 
characteristic  symptom. 

For  the  diagnosis  of  potypous  and  other  tu- 
mours in  the  bronchi,  I  must  refer  the  reader 
to  his  own  reflections  ;  for  as  I  am  convinced 
that  no  one  can  become  a  good  auscultator  by 
the  use  of  his  ears  and  memory  only,  so  do  I 
maintain  that  by  a  knowledge  of  the  properties 
of  sound,  and  a  happy  generalization  of  its  phe- 
nomena, an  observer  will  be  enabled  to  ex- 
plain and  appreciate  not  only  all  those  signs 
that  experience  has  hitherto  discovered,  but 
those  that  may  also  be  revealed  by  future  ob- 
servation. Thus  he  who  knows  how  the  sono- 
rous and  sibilant  rhonchi  are  produced,  will 
perceive  that  a  tumour  pressing  on  a  bron- 
chus may  likewise  cause  them.  He  will  see,  in 
a  haemorrhage  simply  bronchial,  all  the  ele- 
ments necessary  to  produce  the  mucous  rhon- 
chus, &c. 


SPASMODIC    ASTHMA.  89 

Section  V. — Spasmodic  Jlsthma. 

Before  the  discovery  of  auscultation,  this 
name  was  given  to  dyspnoea  arising  from 
many  other  causes  than  that  to  which  patholo- 
gical research,  and  a  more  perfect  method  of  di- 
agnosis, have  now  restricted  it.  Besides  the 
real  spasmodic  disorder,  dry  catarrh,  emphy- 
sema of  the  lungs,  diseases  of  the  heart,  &c, 
sometimes  affect  the  breathing  in  a  manner  so 
sudden,  and  for  a  period  so  transitory,  that  in 
defect  of  less  equivocal  signs,  the  dyspnoea  has 
been  ascribed  to  an  irregular  action  of  the  bron- 
chial muscles.  Thus,  a  pathological  state  was 
supposed  to  prove  the  existence  of  bronchial 
muscles  which  anatomical  research  had  never 
clearly  discovered.  A  more  perfect  examination 
demonstrated  to  Reisseissen  the  anatomical 
point ;  and  M.  Laennec  has,  in  a  limited  degree, 
established  the  assumed  pathological  state,  in 
proving  the  occurrence  of  a  purely  spas- 
modic asthma, 

During  the  paroxysm  the  chest  sounds  ill  on 
percussion,  and  the  respiratory  murmur  is  in- 
distinct, even  on  the  most  forcible  respiration. 
But  if  the  patient,  after  holding  his  breath  a  lit- 
tle while,  be  desired  to  breathe  again  quietly,  the 
spasm  will  be  overcome  as  it  were  by  surprise, 
and  the  entry  of  the  air  into  the  cells  will  be 
12 


90  SPASMODIC    ASTHMA. 

heard  in  a  clear,  and  sometimes  puerile  sound. 
This  may  be  best  effected  in  the  manner  recom- 
mended by  Laennec,  by  desiring  the  patient  to 
read  aloud,  or  speak  as  many  words  as  he  con- 
veniently can  without  taking  breath,  and  then 
to  breathe  at  his  ease.  But  after  one  or  two 
inspirations,  the  spasm  regains  its  hold,  and  the 
respiration  becomes  as  dull  as  ever.  The  dimi- 
nution of  the  respiratory  noise  here,  obviously 
proceeds  from  the  obstruction  opposed  to  the 
entry  of  air  into  the  small  bronchi  and  vesicles 
by  the  tonic  contraction  of  their  muscular 
fibres.  By  the  same  contraction  the  lungs  are 
in  a  manner  collapsed  within  the  thoracic  cavity, 
and  the  parietes  of  the  chest,  falling  in  with 
them,  lose  that  sonorous  elasticity  produced  by 
a  fulness  of  aereal  contents*.  The  chest  thus 
contracted  to  the  size  of  the  collapsed  lungs, 
may  be  compared  to  a  drum,  the  parchment  of 
which  is  pulled  in  by  transverse  strings.  The 
free  vibration  is  thus  checked  by  these  unyield- 
ing frena.  Conceiving,  as  T  do,  that  the  con- 
traction of  the  bronchial  muscles  is  a  sufficient 
cause  of  the  phenomena  of  asthma,  I  gladly 
discard  Laennec's  hypothesis  of  the  active  dila- 
tation of  the  bronchi,  unsupported  as  it  is  by 
physiological  fact,  and  opposed  to  all  we  know 
of  animal  dynamics, 

*  See  my  observations  on  percussion,  p.  29. 


SPASMODIC    ASTHMA.  91 

The  dyspnoea  produced  by  spasm  of  the 
bronchi  is  often  of  long  continuance,  and  may, 
to  a  certain  extent,  become  habitual.  In  such 
cases  the  system  accommodates  itself  to  the  di- 
minished supply  of  air,  and  the  respiratory 
function  is  less  called  into  action  ;  but  slight 
causes,  either  reproducing  the  want  in  the  sys- 
tem, or  increasing  the  spasm,  will  be  sufficient 
to  bring  back  the  dyspnoea.  Of  the  first  class 
of  causes  are  exertion,  the  sudden  application 
of  cold,  &c.  ;  of  the  second,  depressing  affec- 
tions of  the  mind,  and  sympathetic  irritations, 
produced  by  certain  ingesta  in  the  stomach  and 
intestines.  This  second  class  includes  usually 
those  which  originally  produce  the  disease.  I 
have  seen  a  remarkable  and  exquisite  case  pro- 
duced by  the  slow  introduction  of  lead  into  the 
system,  but  such  a  form  of  saturnine  neurosis  is, 
I  believe,  rare. 

This  affection  may  be  partial,  affecting  one 
lung  only,  or  one  more  than  the  other,  and  is 
often  complicated  with  partial  dry  catarrh,  and 
pituitous  or  humoral  asthma.  The  signs  of 
these  diseases  will  then  be  observed  in  some 
parts  of  the  chest,  while  those  pathognomic  of 
the  spasmodic  affection  will  be  heard  elsewhere* 


92  PERIPNEUMONY FIRST    STAGE. 


chap.  ir. 


DISEASES     AFFECTING    THE     TISSUE    OF    THE 
LUNGS. 

Section  I.—Peripneumony. 

Peripneumony  consists  in  an  inflammation 
of  the  parenchyma  of  the  lungs,  and,  according 
to  the  changes  produced  in  the  tissue,  it  is  di- 
vided into  three  stages. 

The  first  is  that  of  simple  inflammatory 
injection,  in  which  the  size  of  the  blood  ves- 
sels is  increased,  and  a  serum,  more  or  less 
abundant,  is  effused  into  the  interstitial  tis- 
sue. Our  knowledge  of  minute  anatomy  does 
not  permit  us  to  specify  with  certaint}^  the 
exact  and  essential  seat  of  this  inflammation  ; 
but  I  am  disposed,  from  a  consideration  of  the 
signs,  and  the  effects  on  the  tissue,  to  refer  it 
principally  to  the  plexus  of  vessels  and  sub- 
mucous tissue  surrounding  and  uniting  the 
minute  extremities  of  the  bronchi.  It  may, 
and  usually  does,  extend  to  the  mucous  mem- 
brane of  these  extremities,  and  of  the  smaller 
bronchial  tubes  ;  but  this  is,  strictly  speak- 
ing, rather  a  bronchitis  necessarily  attendant  on 


PATHOLOGY    AND    SIGNS.  93 

the  parenchymatous   inflammation  than    a  part 
of  the  pneumonia*. 

In  this  stage  of  the  inflammation,  the  dis- 
tended vessels,  and  the  serous  effusion  in  the 
interstices,  press  on  the  minutest  bronchial  ra- 
mifications, and  partially  obstruct  the  ingress 
of  air  into  the  cells  to  which  they  lead  ;  whilst 
the  viscid  secretion  of  the  mucous  membrane, 
simultaneously  inflamed,  filling  the  callibre  of 
the  tubes  thus  narrowed,  only  yields  to  the  air 
in  respiration  forcing  its  way  through  it  in 
successive  bubbles.  This  bubbling  passage  of 
air  through  a  viscid  liquid,  contained  in  an  in- 
finity of  tubes  of  equally  diminished  calibre, 
causes  that  regular  and  equable  crepitation 
which  constitutes  the  true  rhonchus  crepitans. 
If  the  inflammatory  infarctus  be  not  so  general 
as  to  prevent  the  air  from  entering  without 
obstacle  into  many  of  the  bronchial  cells,  then, 
besides  the  crepitant  rhonchus,  the  natural 
sound  of  respiration  will  be  heard.  On  the 
other  hand,  the  inflammation  increasing,  and 
passiug  into  the  second    stage,   causes    a  total 

*  On  dissection,  the  lung  in  this  stage  is  found  to  be  of  a  livid  red 
colour,  of  various  shades  ;  it  is  increased  in  weight,  and  pits  on  pressure, 
but  it  is  still  somewhat  crepitant,  and  usually  floats  in  water.  When  cut 
into,  it  still  presents  its  spongy  structure,*  out  of  which  exudes  abundant- 
ly a  spumous  bloody  serum.  Its  integral  cohesion  is  diminished,  for  the 
texture  may  be  easily  broken  down  between  the  fingers.  The  mucous 
membrane  of  the  small  bronchi  is  of  a  deep  red  colour. 


94      PERIPNEUMONY— SECOND  STAGE. 

obstruction  of  the  cells,  and  all  sound  of  vesicu- 
lar respiration,  and  even  of  crepitant  rhonchus, 
ceases.  The  progress  of  the  inflammation  is, 
therefore,  now  marked  by  the  gradual  dispari- 
tion  of  the  crepitant  rhonchus. 

The  second  stage  of  peripneumony  is  that  in 
which  the  lungs  present  that  change  in  the 
tissue  which  is  called  by  Laennec,  hepatiza- 
tion*. ,  This  change  consists  in  the  effusion  of 
a  semi-solid  albumen  in  the  interstitial  tissues, 
and  which  presses  on,  and  obliterating  the  ca- 
vities of  air-cells  and  smaller  bronchi,  destroys 
the  spongy  texture  of  the  lung,  and  con- 
verts it  into  a  more  or  less  solid  mass.  Such  a 
condition  of  the  air-cells  precluding  any  further 
ingress  of  air,  what  stethoscopic  signs  can  we 
have  to  indicate  this  stage  of  inflammation  in 
the  living  body  ?  Here  still  a  consideration  of 
the  physical  state  of  the  organ  will  teach  us  to 
expect,  a  priori,  the  same  phenomena  that  ex- 
perience has  revealed.  We  have  already  had 
occasion  to  observe  that  the  healthy  lung,  from 
its  being  composed  of  conductors  of  very  dif- 

*  Ramollissement  rouge  of  Andral. — A  hepatized  lung  presents  the  fol- 
lowing characters  after  death  :  Externally  it  is  of  deep  red  colour,  which 
internally  is  mottled  with  a  number  of  small  light  yellowish  granular  spots, 
with  patches  of  whiter  colour,  marking  the  vessels,  membranous  septa,  &c. 
not  affected  with  the  inflammation.  It  sinks  in  water,  and  is  no  longer 
crepitant,  but  breaks  readily  under  the  fingers,  and  may,  by  a  slight  pres- 
sure, be  reduced  to  a  reddish  pulp. 


PATHOLOGY    AND    SIGNS.  95 

ferent  powers,  (air,  membrane  and  liquid)  is  a 
bad  conductor  of  sound,  and  is,  therefore,  in- 
capable of  transmitting  to  its  surface  slight 
sounds,  remote  in  the  interior.  But  now  that 
the  tissue  is  rendered  more  uniformly  dense  by 
hepatization,  it  becomes  a  better  conductor,  and 
transmits  a  sound  (usually  unheard,)  of  the  air 
passing  to  and  fro  in  the  larger  bronchial  ramifi- 
cations. This  is  the  bronchial  respiration  of  La- 
ennec  and  Andral ;  and  specfically  marks  the 
second  stage  of  pneumonic  inflammation.  This 
sound,  when  once  heard,  cannot  be  mistaken. 
It  resembles  that  produced  by  blowing  through 
a  crow's  quill,  and  is  frequently  so  loud  as  al- 
most to  amount  to  a  whistle.  This  sound, 
acute  and  defined,  forms  a  remarkable  contrast 
with  the  dull,  diffused  sigh  of  natural  vesicular 
respiration. 

Another  neariy  as  characteristic  sign  is  given 
by  the  voice.  When  the  stethoscope,  with  its 
stopper  in,  is  applied  to  the  diseased  part,  the 
voice  is  heard  to  resound  there  in  a  tone  modi- 
fied, as  if  speaking  through  small  tubes.  The 
voice  does  not,  as  in  pectoriloquy,  appear  to 
enter  the  tube  of  the  instrument ;  and  the 
sound  of  the  voice  is  not  heard  in  distinct 
words,  but  in  notes  of  various  continuance,  not 
always  synchronous  with  the  words  uttered  by 
the  mouth  ;    and  the   intervals  are   often   alter- 


96  PERIPNEUMONY SECOND    STAGE. 

nated  with  what  may  be  called  whiffs  of  bron- 
chial respiration. 

It  is  obvious  that  the  extent  and  intensity  of 
these  sounds  must  greatly  depend  on  the  num- 
ber and  size  of  the  bronchial  tubes  in  which 
they  are  heard.  They  are  therefore  most  dis- 
tinct when  the  hepatization  occupies  the  sum- 
mit or  the  neighbourhood  of  the  root  of  the 
lung,  and  extends  to  the  surface.  On  the 
other  hand,  when  the  surface  or  the  centre  alone 
is  hepatized,  these  signs  may  be  altogether  want- 
ing. 

In  the  third  stage  the  diseased  lung  becomes 
infiltrated  with  a  purulent  matter,  which  is 
generally  consistent  at  first,  but  soon  acquires 
the  liquidity  of  common  pus*.  In  this  stage 
the  bronchial  respiration  and  vocal  resonance 
usually  cease,  and  are  sometimes  supplanted 
by  a  gurgling  mucous  rhonchus,  indicating  the 
presence  of  a  liquid  in  the  principal  bronchial 
trunks. 

In  the  rare  case  of  the  formation  of  an 
abscess  in  the  hepatized  lung,  the  passage  of 
air  through  the  liquid   will  be  indicated  by  the 

*  This  changes  the  colour  of  the  diseased  lung  from  the  red  of  hepatiza- 
tion to  discoloured  yellow  or  brownish,  which  is  frequently  mottled  with 
red  portions  in  the  second  stage,  and  with  the  black  pulmonary  matter. 
This  is  called  by  Andral  ramollissement  grk.  The  tissue  is  quite  imperme- 
able to  air,  and  of  extreme  friability,  being  reducible  by  slight,  pressure  into 
a  kind  of  purilage. 


PATHOLOGY   AND    SIGNS.  97 

gurgling  or  cavernous  rhonchus :  and  when 
the  cavity  has  been  emptied  of  the  pus  by  ex- 
pectoration, pectoriloquy  and  the  cavernous  res- 
piration will  be  added  to  this  sign. 

Gangrene  is  also  [a  rare  termination  of 
peripneumony.  The  gangrenous  portion,  being 
softened  or  ejected  by  expectoration,  will  pro- 
duce a  cavity  which  will  be  indicated  by  the  usu- 
al signs  of  cavernous  rhonchus  or  resonance. 
The  distinctive  physical  sign  of  gangrene  is  the 
foetid  odour  emitted  from  the  diseased  part  in 
respiration*. 

Thus  far  we  have  traced  peripneumony  in  the 
changes  in  the  pulmonary  textures,  as  indicated 
by  the  stethoscope.  The  severity  of  the  case 
may  be  judged  from  the  extent  of  the  disease, 
and  the  advances  which  it  has  made. 

It  is  in  the  first  stage  of  inflammatory  injection 
that  auscultation  proves  pre-eminently  useful, 
in  assuring  us  of  the  existence  of  a  disease 
that  no  other  symptoms  could  discover.  The 
presence  of  the  rhonchus  crepitans  may  be 
taken  as  a  warning  to  resort  to  energetic  anti- 
phlogistic  measures,    which   in   this   stage    will 

*  The  anatomical  characters  of  gangrene  of  the  lung  are  various.  The 
colour  is  sometimes  like  that  of  a  simply  engorged  lung,  with  a  greenish 
tint.  Sometimes  it  presents  a  dark  green,  or  an  earth-brown  aspect.  In 
its  progress  the  gangrene  produces  a  softening  and  complete  deliquescence 
of  the  pulmonary  tissue :  but  the  sphacelic  foetidity  is  the  characteristic 
sign. 

13 


98  PERIPNEUMONY. 

seldom  fail  in  arresting  its  course.  The  disap- 
pearance of  this  sign,  and  sometimes  the  pre- 
sence of  the  bronchial  respiration  and  rhonchus, 
announce  the  increasing  danger  and  progress  of 
the  disease,  as  they  indicate  its  advance  to  the 
second  stage.  The  diseased  structure  is,  how- 
ever still  susceptible  of  a  return  to  the  healthy 
state,  and  the  view  which  we  have  taken  of  the 
morbid  anatomy  of  this  stage  suggests,  in 
addition  to  means  directed  against  the  inflam- 
matory orgasm,  the  important  advantage  with 
which  sorbefacients  may  be  used.  I  know 
of  no  symptom  by  which  the  third  stage  can 
be  recognised  during  life  ;  unless  it  be  occasion- 
ally by  the  presence  of  the  gurgling  mucous 
rhonchus  before  mentioned.  In  this  stage  the 
disorganization  has  probably  gone  so  far  that 
the  texture  cannot  be  restored  ;  and  yet  it  is  pro- 
bable that  even  then  recoveries  have  been 
brought  about  by  the  formation  of  abscess*. 
How  far  a  cure  may  be  effected  by  any  other 
process  we  are  not  able  to  determine.  Recove- 
ry from  peripneumony,  terminating  in  gangrene, 
is  of  still  more  dubious  possibility.  I  know  of  no 
fact  to  warrant  the  supposition,  but  the  extreme 
rarity  of  the  case  renders  the  matter  of  little  im- 
portance. 

The  resolution   or  retrogression  of  peripneu- 

*  Laennec,  Tom.  I.  p.  409. 


PERIPNEUMONY— SIGNS    OF    CURE,  99 

monic  inflammation,  is  attended  by  a  succession 
of  the  same  physical  signs  that  marked  its  pro- 
gress, but  in  an  inverted  order.  Thus,  in  a 
spot  where  no  sound  of  the  ingress  or  egress  of 
air  has  been  heard,  or  perhaps  only  a  bronchial 
respiration,  a  slight  crepitant  rhonchus  begins 
to  be  distinguished  at  the  end  of  each  inspira- 
tion, apparently  produced  by  the  air  again  gain- 
ing a  straitened  admittance  through  a  few  of  the 
bronchial  tubes,  whose  calibres  have  been  par- 
tially restored  by  the  re-absorption  of  matter 
effused  round  their  parietes.  This  sign  increases 
in  intensity  as  the  resolution  proceeds  ;  the 
bronchophony  and  bronchial  respiration  are 
diminished  as  the  lung  re-acquires  its  spongy 
texture,  and  becomes  a  worse  conductor  of 
sound.  After  a  while  the  natural  respiratory 
murmur  is  heard  mixed  with  the  crepitant 
rhonchus  ;  and  as  the  texture  becomes  more 
permeable  to  the  air,  this  increases  as  that 
diminishes,  and  the  healthy  function  of  the  lung 
is  thus  gradually  restored.  But  here  again  the 
signs  obtained  by  auscultation  are  invaluable, 
as  they  alone  indicate  with  certainty  the  absence 
of  the  disease.  The  dyspnoea  may  have  been 
removed,  the  cough  may  have  ceased,  the  ex- 
pectoration may  have  become  simply  catarrhal, 
the  pulse  natural,  and  all  febrile  symptoms  dis- 
appeared ;  and  yet  the  auscultator  detects  the 


100  PARTIAL    PERIPNEUMONY. 

lurking  disease  in  theng^usiafl.ge  of  the  crepi- 
tant rhonchus  ;  aj^d^^tol^ailh^^e^tinues,  a 
slight  exposure  to  cold,  or  a  trivial  departure 
from  antiphlogistic  regimen  may  cause  a  r^japse, 
which,  in  a  subject  already  reduced  fyy,  Reple- 
tion, may  be  more  difficult  to  cure  tb6n  the 
original  disease.  ^^fo/7"Y  Qp  \h^^yr 

I  have  here  described  the  access,  progress, 
and  cure  of  pneumonia  in  its  general  well- 
marked  course  ;  it  will  now  be  necessary  to  ad- 
vert to  certain  varieties  in  the  signs  produced 
by  situation,  extent,  and  complication  of  the 
pneumonic  inflammation. 

When  the  inflammation  occupies  the  central 
part  of  the  lung,  and  particularly  of  the  base? 
without  extending  to  the  surface,  the  experi- 
enced ear  alone  can  distinguish  the  crepitant 
rhonchus  in  the  first  stage,  and  the  bronchial 
respiration  and  resonance  of  the  second,  at  a 
distance,  through  the  natural  sound  of  the  respi- 
ration, which  comes  from  the  healthy  portions 
at  the  surface.  Whenever  the  inflammation 
occupies  a  considerable  portion  of  the  organ, 
the  sound  of  the  respiration  in  the  healthy 
parts  is  much  louder  than  usual,  and  is  called 
puerile  from  its  resemblance  to  the  noisy  respi- 
ration of  children,  or  supplementary  from  its 
being  increased  to  supply  the  defective  entrance 
of  air  in  the  diseased  parts.    The  intensity  of  this 


SIGNS    BY    AUSCULTATION.  1  0  1  ^ 

supplementary  respiration  will  depend,  besides, 
on  the  extent  of  the  disease,  on  the  natural  ac- 
tivity of  the  respiratory  function,  the  want  of 
breath,  so  different  (as  we  have  before  remark- 
ed) in  different  individuals. 

M.  Andral  has  remarked,  that  in  the  compli- 
cation of  pneumonia  with  catarrh,  the  loud  mu- 
cous rhonchus  of  the  latter  so  completely  ob- 
scures the  rhonchus  crepitans  of  the  former 
disease,  that  this  may  escape  detection ;  but 
I  am  inclined  to  agree  with  Laennec,  that 
there  are  few  cases  in  which  the  practised 
auscultator,  assisted  by  the  stethoscope,  cannot 
distinguish  the  presence  and  seat  of  both  symp- 
toms*. The  ear,  by  practice,  acquires  a  great 
facility  in  separating,  and  listening  to  a  single 
sound  from  amongst  several  others,  perhaps 
superior  in  loudness.  Nor  let  this  appear  sur- 
prising, when  it  is  remembered  that  we  are  ha- 
bitually accustomed,  in  the  din  of  a  city,  to  dis- 
tinguish and  be  attentive  to  each  of  the  mul- 
titude of  sounds  of  various  intensity  that  beset 
our  earsf. 

Percussion,   though  much  inferior  to  auscul- 


ien  mixed  with  other  rhonchi,  the  crepitant  rhonchus  is  lust  distin- 
guished at  the  end  of  each  inspiration,  that  being  the  part  of  respiration  the 
most  purely  risenkvr. 

j  We   effect  this,  I   apprehend,  by  the  voluntary  tension  or  relaxation 
of  the  tympanum,  by  which  it  is   made  mire  susceptible  of  the  vibratiun 


102  PERIPXEUMONY. 

tation  in  extent  and  certainty  of  its  indications, 
is  }et  of  great  utility  to  confirm  and  assist  it. 
In  the  first  stage  the  chest  often  sounds  well  in 
the  diseased  part,  or  at  least  the  diminution  of 
the  sound  is  doubtful,  whilst  the  rhonchus  cre- 
pitans unequivocally  proclaims  the  presence  of 
the  inflammation.  On  passing  to  the  second 
stage,  however,  the  sound  is  evidently  duller 
and  in  the  second  and  third  stages  becomes 
quite  mat,  and  continues  to  be  so  until  resolu- 
tion brings  it  to  its  first  stage  again. 

Percussion  gives  no  indication  when  the  in- 
flammation is  central ;  and  it  requires  much 
practice  to  detect  by  it  a  small  circumscribed 
inflammation  on  the  surface.  Its  indications 
are  always  doubtful  at  the  posterior  and  lateral 
margins  of  the  lungs,  on  account  of  the  vicinity 
of  the  abdominal  viscera. 

The  peripneumonic  inflammation  modifies 
the    secretion  of  the    bronchial  mucous   mem- 


of  one  particular  sound,  by  being  brought  in  unison  or  at  least  in  har_ 
mony  with  it.  Thus  discordant  sounds,  or  those  not  separated  by  har- 
monic intervals,  are  easily  distinguished,  but  harmonic  sounds  being 
blended  with  each  other,  are  with  more  difficulty  separated,  and  this 
difficulty  is  in  proportion  to  the  perfection  of  the  harmony  ;  thus  it  is 
greatest  with  unison,  next  the  octave,  the  fifth,  the  third,  &c.  This  fact 
is  Of  importance  in  auscultation,  the  indications  of  which  may  be  obscur- 
ed by  similar  extraneous  sounds.  Thus  a  tinnitus  aurium  in  the  auscul- 
tator,  or  the  rustling  of  the  clothes  of  the  patient,  may  prevent  the  respi- 
ratory murmur  from  being  distinguished,  whilst  a  sibilant  rhonchus  may 
at  the  same  time  be  heard  with  its  usual  force. 


SPUTA.  103 

brane  in  a  very  remarkable  manner.  At  the 
commencement  of  the  disease  there  is  fre- 
quently no  expectoration,  or  it  is  simply  ca- 
tarrhal, being  composed  of  a  mucous  of  mode- 
rate tenacity  ;  but  as  the  crepitant  rhonchus 
becomes  marked,  the  sputa  assume  their  cha- 
racteristic form.  They  are  semi-transparent, 
tenacious,  and  run  together,  forming  one  mass 
of  a  reddish  yellow,  or  rusty  tinge  of  vari- 
ous shades.  As  the  disease  advances,  this  te- 
nacity increases.  At  first  it  does  not  much 
exceed  that  of  the  white  of  an  egg,  and  when 
poured  out,  the  sputa  fall  in  glutinous  strings, 
but  at  the  height  of  the  first  stage  they  are  fre- 
quently so  viscid,  that  inverting  the  vessel,  and 
even  shaking  it  in  this  position,  will  not  suffice 
to  detach  them  from  it.  The  same  tena- 
cious property  imprisons  in  the  mass  a  multi- 
tude of  little  air  bubbles,  which  sometimes  pro- 
duce a  spumous  appearance.  The  colour  may 
vary  in  numberless  gradations  from  a  light  red- 
dish or  greenish  yellow,  to  a  deep  orange  or 
rusty  hue.  All  these  tints  proceed  from  various 
proportions  of  blood  intimately  combined  with 
the  secretion  of  the  bronchial  membrane. 

Quite  different  from  these  are  the  sanguino- 
lent  sputa  that  sometimes  occur  in  catarrh,  in 
which  the  blood  appears  in  distinct  striae.  The 
intimately   combined    tint,    and    the    glutinous 


104  PERIPNEUMONY. 

viscidity   of  peripneumonia  expectoration,    give 
to  it  a  character   perfectly    pathognomic,  and 
sufficient  in   itself  to  prove  the  presence    of  the 
disease.      Moreover,    the    degree   of  viscidity 
announces,  with  tolerable  precision,  the  inten- 
sity of  the   inflammation  ;    and   whenever,  after 
having  become  thinner  in  the  course  of  cure,  the 
sputa  regain  their   former  viscidity,   a  relapse 
into   the    disease   is   indicated.      But   although 
the   presence    of  these    sputa    indicates    with 
certainty    the   existence    of   pulmonic     inflam- 
mation, we  cannot  draw  an  opposite  conclusion 
from  their  absence.     They  rarely   appear  until 
the   second   or   third   day,    sometimes   not    till 
later,  and  in  some  cases  have  not  been  observed 
at  all.     So  also  in  the  cure;  they  usually  disap- 
pear,   and   the   expectoration    becomes   simply 
catarrhal  some  time  before  the  cessation  of  the 
rhonchus   crepitans.     They  sometimes  continue 
during   the   stage    of    hepatization,     but   more 
commonly    become    pituitous,   or  mucous   and 
opake.     In   the  third   stage   the   expectoration 
sometimes    consists   of  an    opake    mucus,    oc- 
casionally   mixed    with    pus ;     but    more    fre- 
quently,   I  think,  it  resembles   a  thin   mucilage 
coloured  with  treacle.     This  peculiar  form  of  the 
sputa  first  noticed  by  MM.  Lerminier  and  An- 
dral,  M.  Laennec  considered  merely  fortuitous, 
and  to  proceed  entirely  from  spongy  and  bleed- 


PATHOLOGY.  105 

ing  gums,  id  cachetic  subjects  ;  but  in  this  opin- 
ion, I  do  not  think  lie  is  borne  out  by  experi- 
ence. The  appearance  of  such  an  expectoration 
must,  at  any  rate,  be  viewed  as  a  very  unfavour- 
able symptom. 

Section  II. — Emphysema  of  the  Limgs. 

Emphysema  of  the  lungs  consists  in  a  general 
dilatation  of  the  air  vesicles,  whereby  the  tissue 
is  rendered  coarser  and  less  dense.  To  under- 
stand more  fully  the  nature  of  the  alteration,  it 
will  be  requisite  to  study  the  manner  in  which  it 
is  produced. 

In  cases  of  chronic  catarrh,  particularly  of  the 
dry  kind,  the  minute  bronchial  ramifications  be- 
come so  obstructed  by  the  swelling  of  their 
membrane,  or  by  the  secretion  of  a  viscid 
mucus,  that  the  air  can  only  be  forced  through 
them  into  the  vesicles  by  a  considerable  effort. 
Now,  as  in  ordinary  respiration,  the  inspiration 
(a  muscular  effort,)  is  more  forcible  than  the 
expiration,  which  is  principally  effected  by 
the  elastic  force  of  the  cartilages  of  the  ribs, 
and  the  weight  of  the  abdominal  viscera,  the 
former  may  prove  sufficient  to  overcome  the 
obstacle  to  the  introduction  of  air  into  the 
vesicles,  while  the  latter  is  inadequate  to  effect 
its  expulsion.  Successive  portions  of  air,  ex- 
panding by  the  increased  temperature,  are  thus 
14 


106  EMPHYSEMA   OF    THE    LUNGS. 

introduced  and  incarcerated  in  the  cells,  which 
are  thereby  kept  in  a  state  of  continual  dilata- 
tion. This  is,  perhaps,  a  first  and  principal 
cause  of  the  dilatation  of  the  air-cells  ;  but 
other  causes  co-operate,  and  other  changes  are 
produced,  before  the  emphysema  becomes  per- 
manent, 

The  forcible  action  of  the  expiratory  muscles 
in  coughing  will  exert  a  pressure  on  the  dilated 
air-cells.  This  pressure  may  overcome  the  ob- 
stacle in  the  bronchi,  expel  the  air,  and  restore 
the  cells  to  their  natural  size.  But  the  obstruc- 
tion may  have  increased,  and  then  the  pressure 
will  expand  the  cells  in  the  direction  of  the 
adjacent  yielding  tissue.  The  dilated  cells  will 
thus  encroach  upon  the  adjoining  healthy  tissue, 
and  cause  its  obliteration  (a  new  obstruction 
in  the  bronchi),  or  the  rupture  of  its  cells.  Add 
yet  another  cause,  which  may  occasionally  act, 
and  we  shall  have  found  explanations  enough 
of  the  frequent  occurrence  of  a  disease,  the  very 
existence  of  which  has  not,  till  of  late,  been 
suspected.  In  dry  chronic  catarrh,  the  general 
starting  point  of  emphysema,  small  particles  of 
viscid  mucus  form  a  kind  of  moveable  obstruc- 
tion, which,  falling  into  a  bronchial  ramifica- 
tion, instantaneously  and  effectually  plug  up 
the  tube.  Now,  suppose  this  to  happen  in  a 
tube  at  the  termination  of  an  expiration  j  inspi- 


PATHOLOGY.  107 

ration  takes  place,  but  this  pellet  of  mucus  acts 
as  a  valve,  preventing  the  entry  of  air  into 
those  cells  supplied  by  this  tube,  the  conse- 
quence is,  that  the  air  in  the  surrounding  cells 
presses  in  to  fill  the  vacuum,  by  dilating  or  rup- 
turing their  membranous  tunics. 

Such  a  variety  of  causes,  acting  and  re-acting 
upon  each  other,  tends  to  produce  this  organic 
derangement.  How  strikingly  does  this  prove 
the  exactitude  and  perfection  with  which  the 
machine  must  act  to  preserve  health,  since  so 
slight  a  deviation  may  entail  such  disorder ; 
and  how  wonderful  that  the  equilibrium  is  not 
more  frequently  lost !  Besides  the  simple  dila- 
tation of  the  air  vesicles,  there  appears  to  be 
sometimes  an  intervesicular  emphysema,  which 
causes  the  occlusion  of  some  bronchial  branches. 
To  this,  and  to  an  increased  rigidity  of  the 
tunics  of  the  dilated  cells,  is  to  be  ascribed  the 
tense  elasticity  so  remarkable  in  an  emphyse- 
matous lung;  hence,  too,  the  incapacity  of  the 
lung  to  perform  its  function  with  effect.  This 
incapacity  is  also  manifested  during  life,  by  the 
absence  or  diminution  of  the  respiratory  sound 
in  the  part.  This  leads  me  to  consider  the  phy- 
sical signs  of  emphysema. 

It  not  unfrequently  happens  that  emphysema 
is  present  without  producing  any  other  signs 
than  those  of  dry   catarrh  or  asthma  ;  namely, 


108  EMPHYSEMA   OF   THE    LUNGS. 

a  diminished  sound  of  respiration,  with  slight 
sibilant  or  mucous  rhonchus,  and  clear  sound  on 
percussion  ;  and  then  the  duration  of  the  disease 
can  alone  serve  as  a  distinction.  But  if  the 
emphysema  be  more  extensive,  it  will  give  to 
the  chest  an  unnaturally  rounded  form,  with  in- 
creased intercostal  spaces.  If  one  lung  only  be 
affected,  the  corresponding  side  alone  will  pre- 
sent this  appearance  :  it  will  be  larger  than  the 
other,  and  emit  a  clearer  sound  on  percussion. 
The  stethoscope  may  discover  from  time  to  time 
a  dry  crepitant  rhonchus  of  a  peculiar  kind,  and 
which  pretty  closely  resembles  the  sound  pro- 
duced by  inflating  forcibly  the  cellular  mem- 
brane of  meat.  This  sound  is  caused  by  the 
motion  of  air  in  the  intervesicular  texture,  or 
particularly  under  the  pleura,  during  the  respi- 
ratory movements,  and  is  clearly  the  same  as  that 
which  may  be  produced  by  pressure  on  subcu- 
taneous emphysema.  More  rarely,  the  sound 
resembles  the  friction  of  a  pulley,  or  that  of  two 
pieces  of  leather  rubbed  together,  and  this  is 
usually  confined  to  inspiration.  I  have  some- 
times heard  these  sounds  produced  not  only  by 
the  action  of  respiration,  but  also  by  the  im- 
pulse of  the  heart ;  which  shows  that  they  are 
not  of  the  nature  of  other  rhonchi. 

The  expectoration  is  usually  like  that  of  dry 


INTERLOBULAR    EMPHT8£MA.  109 

catarrh,   but  often  more  liquid,   and    of  a  dirty 
grey  colour. 

It  appears  that  emphysema  of  the  lung,  as  it 
"commences  gradually,  and  proceeds  slowly,  is 
not  attended  with  any  immediate  danger ;  but 
it  produces  an  habitual  dyspno2a,  which  incapa- 
citates the  body  for  exertion,  and  renders  it  ob- 
noxious to  serious,  and  even  fatal  effects  from 
contingent  pulmonary  disease,  which  in  a  heal- 
thy lung  might  be  borne  with  comparative  impu- 
nity. 

Interlobular  emphysema  rarely  accompanies 
the  last  affection.  More  frequently  it  occurs 
separately,  and  is  caused  instantaneously  by 
violent  straining,  or  by  some  analogous  exertion 
of  the  respiratory  organs.  As  its  name  implies, 
it  consists  in  an  effusion  of  air  into  the  celular 
tissue,  between  the  lobules  composing  the  lobes 
of  the  lungs,  and  is  strictly  confined  to  it.  This 
emphysema  causes  a  slight  elevation  on  the 
lung,  from  the  interlobular  spaces  which  it  has 
made  :  and  this  elevation  rubbing  against  the 
costal  pleura  in  the  motions  of  respiration, 
causes  a  strepitus,  which  I  have  already  com- 
pared to  that  produced  by  rubbing  together 
slowly  and  forcibly  two  pieces  of  leather.  It  is 
usually  most  perceptible  at  the  end  or  acme  of 
inspiration  ;  but  may  accompany  both  inspira- 
tion and  expiration,  and  then  is  sometimes  heard 


110  (EDEMA    OF    THE    LUNGS. 

in  such  regular  jerks,  that  it  resembles  the  steps 
of  a  person  mounting  and  descending  a  ladder. 
The  impression  conveyed  to  the  ear  is  exactly 
that  of  a  body  rubbing  along  the  ribs,  rising  in* 
inspiration,  and  descending  in  expiration.  The 
friction  likewise  often  communicates  a  corres- 
ponding vibration  in  the  thoracic  parietes, 
which  may  be  felt  by  the  hand.  The  patient 
himself  is  sometimes  sensible  of  a  kind  of  crack- 
ing in  his  chest.  Interlobular  emphysema  may 
produce  at  first  some  difficulty  of  breathing, 
but  never  to  a  serious  extent,  and  is  spontane- 
ously cured  in  time  by  the  gradual  absorption 
of  the  air. 

Section  III.— (Edema  of  the  Lungs. 

This  is,  properly  speaking,  a  serous  effusion 
in  the  interstitial  tissue  between  the  air-cells, 
and  vascular  rete,  by  which  these  are  con- 
nected together.  When  contained,  however, 
by  membranes  of  such  extreme  tenuity,  it  is 
not  surprizing  that  some  serum  should,  by 
transudation,  pass  into  the  air-cells  themselves*. 

*  Accordingly  it  is  so  found  on  examination  after  death.  An  cedema- 
tous  lung  does  not  collapse  ;  on  opening  the  chest,  it  feels  weighty,  and 
pits  on  pressure,  but  is  still  crepitant.  Its  vesicular  texture  is  less  per- 
ceptible than  usual.  When  cut  into,  it  exudes  a  clear,  yellowish  serum, 
scarcely  frothy,  which  appears  to  proceed  from  all  parts  equally.  It  is, 
however,  highly  probable,  that  it  is  secreted  in  the  interstitial  texture, 
which  is  internal,  and  therefore  serous,  and  not  from  the  membrane  of  the 
air-cells,  which  is  mucous. 


PATHOLOGY    AND    SIG.V^.  Ill 

Now  this  liquid,  by  swelling  up  the  interstitial 
texture,  so  presses  on,  and  partially  obstructs 
the  smaller  bronchi,  that  the  air  passing  through 
the  liquid  contained  in  them  produces  a  kind 
of  humid  crepitation,  like  that  heard  on  ap- 
proaching the  ear  to  aliquid  in  gentle  efferves- 
cence, as  bottled  cider,  or  ale,  when  freshly 
poured  out  of  the  bottle.  This  is  the  subcre- 
pitant  rhonchus.  It  differs  from  the  crepitant 
in  the  bubbles  seeming  less  regular  and  more 
humid,  but  it  must  be  considered  different  only 
in  degree  ;  for  the  two  pass  by  insensible  gra- 
dations into  each  other.  The  respiratory  mur- 
mur that  is  heard  with  this  rhonchus  is  feeble, 
particularly  in  comparison  with  the  energetic 
action  of  the  respiratory  machine.  The  reson- 
ance of  the  chest  on  percussion  is  often  not 
perceptibly  diminished,  but  it  is  distinctly  so 
where  the  dyspnoea  is  oppressive,  and  the  oedema 
profuse  and  extensive.  The  expectoration  is 
usually  copious,  consisting  of  a  slightly  viscid, 
colourless  liquid.  This,  when  present,  will 
distinguish  the  disease  from  the  first  stage  of 
peripneumony  ;  but  sometimes  there  is  little  or 
no  expectoration,  and  then  the  diagnosis  must 
be  drawn  from  the  general  symptoms,  as  the 
other  physical  signs  are  so  nearly  the  same. 

CEdema  of  the  lung  is  rarely  idiopathic.  It 
most  frequently    accompanies  organic  diseases 


112  PULMONARY    APOPLEXY. 

of  the  heart  of  long  duration,  and  humoral  ca- 
tarrh, in  which  cases  it  is  often  the  immediate 
cause  of  death.  It  sometimes  succeeds  to  fe- 
brile affections,  particularly  .the  exanthemata, 
being  the  cause  of  the  dyspnoea  sometimes  oc- 
curring after  scarlatina,  rubeola,  &c. 

There  is  one  complication  of  oedema  which 
renders  it  very  difficult  to  recognise,  namely, 
with  emphysema  of  the  lungs.  When  this  is 
present  the  sound  of  respiration  is  so  obscure 
that  it  is  difficult  to  recognise  any  other  sign 
than  an  occasional  sibilation,  whilst  the  sound 
on  percussion  is  very  good.  A  forcible  inspir- 
ation after  coughing,  or  retaining  the  breath 
for  a  while,  will,  however,  frequently  discover 
the  disease,  by  rendering  audible  the  subcrepi- 
tant  rhonchus. 

It  is  always  important  to  be  able  to  discover 
the  presence  of  oedema  in  the  lungs,  for,  al- 
though usually  a  consequence  of  other  disease, 
it  is  always  to  be  considered  a  principal  object 
of  treatment. 

Section   IV. — Pulmonary    Apoplexy    or  H<e- 

morage. 

This  appears  to  consist  in  the  effusion  of 
blood  into  the  parenchyma  and  vesicular  struc- 
ture of  the  lung.  Whether  this  effusion  is  al- 
ways in  consequence  of  the  rupture  of  vessels, 


PATHOLOGICAL    CAUSES    AND    SIGNS.         113 

or  is  sometimes  simply  an  hamiorrhagic  exuda- 
tion, has  not  been  distinctly  ascertained  ;  but 
the  former  cause  would  seem  better  to  explain 
the  suddenness  and  quantity  of  the  hemor- 
rhage, and  the  circumscribed  from  of  the  lesion. 
It  is,  however,  highly  probable  that  the  tex- 
tures are,  in  most  cases,  softened  or  altered  by 
disease,  before  the  rupture  takes  place. 

The  blood  effused  may  coagulate  before  it 
reaches  any  large  bronchial  ramification,  and, 
in  that  case,  there  will  be  no  hsemoptoe,  but 
more  commonly  the  reverse  happens  ;  more  or 
less  blood  is  spit  up,  or,  if  in  large  quantity, 
more  properly,  as  Laennec  observes,  vomited  ; 
for  the  discharge  is  produced  by  a  convulsive 
action  of  the  abdominal  muscles,  exactly  after 
the  manner  of  vomiting.  At  length,  however, 
the  hemorrhage  is  checked  by  the  formation  of 
a  coagulum,  which,  pervading  completely  a 
circumscribed  portion  of  the  pulmonary  tex- 
ture, constitutes  the  hcemoptoic  engorgement  of 
Laennec  *. 

When  a  point  of  the  lung  is  thus  affected,  the 
respiratory  murmur  will,  of  course,  be  no  longer 

*  These  spots  of  pulmonary  apoplexy  arc  of  a  deep  brown  red  colour  ; 
the  coarser  parts  of  the  pulmonary  structure  alone  can  be  distinguif 
in  them,  but  even  these  partake  of  the  same  tinge.  T'nlt  >s  th<  J  are  very 
recent  their  consistence  is  firm,  and  they  contain  little  or  no  sen  •). 
Sometimes  there  is  an  obvious  detritus  in  the  centre,  formed  of  grumous 
blood  alone,  in  which  no   texture  can  be  traced. 

15 


114  PULMONARY    APOPLEXY. 

heard  there  ;  and  if  the  engorgement  be  of  large 
size,  there  will  be  a  corresponding  dulness  of 
sound  on  percussion,  in  that  part  of  the  chest. 
The  compression  of  the  tissue  immediately 
around,  and  the  presence  of  a  bloody  serum  in 
the  vesicles,  proceeding  from  the  coagulum, 
occasions  a  crepitant  rhonchus,  which  is  there- 
fore heard  around  the  spot  where  the  respira- 
tion is  inaudible.  This  symptom,  however, 
seldom  continues  long  after  the  commencement 
of  the  disease,  but,  once  heard,  it  distinguishes 
it  from  a  simple  bronchial  haemorrhage. 

During  the  haemoptoe,  as  in  the  latter  dis- 
ease, the  blood  in  the  bronchi  causes  a  bubbling 
rhonchus,  which  Laennec  distinguishes  from 
that  produced  by  mucus  in  the  bubbles  burst- 
ing in  more  frequent  succession.  The  stetho- 
scopic  symptoms  with  haemoptoe  are  amply  suf- 
ficient to  indicate  the  nature  of  the  disease  ;  but 
when  hsemoptoe  is  not  present,  the  sputa  and 
general  symptoms  must  be  referred  to,  to  esta- 
blish the  diagnosis. 

The  extent  of  the  haemoptoic  engorgement, 
rather  than  the  quantity  of  blood  brought  up, 
indicate  the  degree  of  danger  to  be  apprehend- 
ed ;  for  a  large  quantity  of  blood  may  pass 
through  a  small  rupture  in  the  pulmonary  tis- 
sue, and  unless  this  be  so  great  as  to  threaten 
inanition,   which  is   not  often   the   case    where 


PROGNOSIS.  115 

prompt  measures  are  resorted  to,  the  lesion  is 
more  of  the   nature  of  a   simple  wound  than  a 
change    of  structure.     It  is   where  the  spots  of 
hsemoptoic  engorgement  are  numerous  or  large, 
that  we  have  to   apprehend  some  ulterior  cause 
than  a  simple  rupture,  and  whether  this   be  a 
more  frangible  slate  of  the  pulmonary  tissue, 
depending  on  the  presence  of  miliary   granula- 
tions and  other  precursors  of  tubercular  forma- 
tion, or  be  some   modification    peculiar  to  the 
disease   called  pulmonary  apoplexy,   it  must  be 
viewed  as  partaking  in  the    danger  of  the  ge- 
neral or  constitutional   alterations  of  tissue,  that 
are  very  little  within  the  control  of  medicine. 


116  PLEURISY. 


CHAP.  III. 


Section  I.— Pleurisy, 

Inflammation  of  the  pleura  could  be  recog- 
nised by  no  physical  sign,  if  it  were   not  attend- 
ed by  a  serous  effusion  ;    and  it  is  an  interest- 
ing and  satisfactory  result  of  the  researches  of 
modern  pathologists,  that  this  is  almost  univer- 
sally the  case.     It  is   interesting,  as  a  point  of 
general  pathology,  that  inflammation  of  the  se- 
rous membrane  should  necessarily  produce   an 
effusion  ;  and  it  is  satisfactory,    because  it  fur- 
nishes us  with    the  least  fallible  of    all   signs, 
whereon  to  found  our  diagnosis. 

Exquisitely  marked  as  this  disease  is  de- 
scribed to  occur,  by  the  acute  pain  of  the  side, 
oppression  of  the  breathing,  hard  pulse,  decu- 
bitus on  the  affected  side,  cough,  &c,  there  are 
few  practitioners  who  have  not  proved  the  fal- 
lacy of  each  of  these  symptoms  ;  and,  as  we 
shall  presently  point  out,  the  auscultator  finds 
but  uncertainty  in  them  all. 

At  the  first  attack,  before  there  are  any  signs 
of  effusion,  if  the  pain  be  very  acute,  the 
sound  of  respiration  will  be  somewhat  impaired 
on  the  affected  side.     This  is,  however,  merely 


PATHOLOGICAL   NATURE    AND    SIGNS.       117 

in  consequence  of  the  respiratory  action  being 
restrained  on  that  side  by  the  pain,  and  is  equal- 
ly observed  in  pleurodyne. 

The  secretion  of  liquid  by  the  inflamed  pleura 
commences  from  the  beginning  of  the  attack, 
and  instead  of  being,  as  commonly  supposed,  a 
termination  of  pleurisy,  it  is  a  concomitant,  or 
rather,  a  part  of  the  disease  ;  as  the  secretion 
from  the  bronchial  mucous  membrane  is  of 
catarrh.  The  first  signs  of  this  accumulation 
are  obtained  by  percussion.  The  resonance  of 
the  chest  is  commonly  diminished  first  in  the 
inferior  dorsal  and  lateral  regions,  correspond- 
ing to  the  base  of  the  lung.  As  the  effusion  in- 
creases the  dulness  of  sound  gradually  extends 
upwards,  and  becomes  more  pronounced*. 
Sometimes   the   transition   from  the  dull  to  the 


*  The  following  are  the  appearances  on  dissection  in'  different  stage  s 
of  an  acute  pleurisy : — The  inflamed  pleura  presents  many  points  or 
patches  of  a  diffused  redness,  and  a  number  of  red  vascular  ramifications  are 
likewise  seen  distributed  over  it.  Different  parts  of  the  membrane  arc 
covered  with  coagulable  lymph,  and  a  serous  or  seropurulent,  and  some- 
times sanguineous  liquid  is  found  in  the  cavity.  This  liquid,  if  scanty, 
occupies  principally  the  lower  and  posterior  part  of  the  chest  ;  but  when 
abundant  it  envelopes  the  whole  lung.  The  lung  is  found  compressed, 
flaccid  and  less  crepitant,  in  proportion  to  the  quantity  of  liquid.  Some- 
times reduced  to  a  size  not  greater  than  the  hand  of  the  subject,  it  is  push- 
ed by  the  effusion  into  a  small  space  against  the  mediastinum  and  spinal 
column.  In  some  cases  the  lung  is  bound  by  old  adhesions  and  is  then 
pushed  in  a  different  direction.  When  the  adhesions  are  above,  the  lung 
is  displaced  upwards  by  the  effusion  ;  when  the  lower  parts  adhere  (a  Vi  iv 
rare  case,)  the  effusion  occupies  the  upper  part,  and  so  on,  the  lung  being 
always  pressed  against  its  points  of  attachment. 


118  PLEURISY. 

healthy  sounding  parts  is  so  abrupt,  that  a  hori- 
zontal line  will  exactly  divide  them,  and  this, 
when  well  marked,  is  a  very  characteristic  sign. 
The  sound  of  respiration  likewise  becomes  more 
obscure  as  the  liquid  accumulates  between  the 
lungs  and  thoracic  parietes ;  but  the  collection 
of  liquid  must  be  considerable  before  it  becomes 
extinct. 

Before  this,  however,  another  effect  is  pro- 
duced which  gives  rise  to  its  peculiar  signs. 
The  pressure  of  the  effused  liquid  condenses 
the  tissue  of  the  lung,  by  which  we  have  for- 
merly seen  it  is  rendered  a  better  conductor 
of  sound,  and  transmits  noises,  usually  unheard, 
of  the  passage  of  air  and  the  voice  in  the  bron- 
chi. But  this  bronchophony,  and  this  sound  of 
bronchial  respiration,  before  they  can  reach  the 
ear,  must  pass  through  the  serous  stratum 
between  the  pleurae.  How  then  do  they  effect 
this,  and  how  are  they  affected  by  it?  The 
fact  is  this  :  a  respiration  is  usually  heard 
becoming  bronchial  as  the  effusion  increases 
up  to  a  certain  point,  but  then,  as  the  bronchi 
themselves  become  pressed  by  a  further  in- 
crease it  becomes  faint,  and  at  last  ceases. 
If  the  stratum  of  liquid  is  thin  the  bronchophony 
traverses  it,  but,  by*  throwing  it  into  vibrations, 
is  itself  modified,  rendered  sharp  and  tremulous, 
and  as  if  produced  at  the  surface  of  the  lung. 


PHYSICAL    SIGNS — JEGOPHONY.  119 

The  voice,  therefore,  instead  of  being  as  from 
the  mouth,  or  even  simply  diminutived,  as  in  bron- 
chophony, resembles  the  tremulous  bleating  of  a 
goat  or  lamb.  This  modification  of  the  voice 
M.  Laennec  therefore  called  aegophony.  Its 
most  distinctive  mark  is  its  tremulous  or  sub- 
sultory  chatarcter.  In  bronchophony  the  natu- 
ral pitch  of  the  voice  is  sometimes  raised,  but 
in  aegophony  it  is  constantly  and  considerably 
so,  and  is  thus  rendered  squeaking  and  wiry. 

Now  as  this  modification  of  bronchopony 
can  be  caused  only  by  an  effusion  in  the  pleura, 
it  may  be  regarded  as  a  pathognomonic  sign. 
But  even  in  this  case  three  conditions  are  ne- 
cessary before  it  can  be  produced  :  1.  A  cer- 
tain condensation  of  the  pulmonary  tissue  :  2. 
The  presence  of  a  thin  stratum  of  liquid  be- 
tween the  condensed  lung  and  the  thoracic  pa- 
rietes  :  3.  Such  a  proportion  between  the  mass 
of  this  liquid  and  the  pitch  and  strength  of  the 
vocal  sounds,  that  it  may  be  thrown  into  vibra- 
tion by  them.  The  necessity  of  this  latter 
condition  is  shown  in  the  fact  that  certain  tones 
of  the  voice  are  aegophonic,  and  others  not ; 
some  transmitted  with  only  bronchophonic  mo- 
dification, and  others  changed  to  the  sharp 
tremulons  tone  of  aegophony.  I  think  I  could 
give  an  explanation  of  the  change  in  the  note 
or  pitch  of  the  voice  in  this  instance,  but  as  it 


120  ACUTE    PLEURISY. 

hinges  on  the  power  of  different  conductors, 
to  modify  vibrations  in  their  passage  through 
them,  a  subject  hitherto  unnoticed  and  unex- 
plained, it  would  require  consideration  too 
abstract  and  minute  for  this  place.  I  shall  only 
remark  that  the  tremulous  or  subsultory  sound 
of  the  segophonic  voice  is  produced  by  succes- 
sive undulations  of  the  liquid,  the  result  of  an 
irregular  transmission  of  the  sonorous  vibrations*. 
It  may  be  concluded  from  this  account  of  the 
proximate  or  physical  causes  of  segophony,  that 
this  symptom  cannot  usually  continue  for  any 
length  of  time.  The  liquid  is  either  so  much  in- 
creased that  the  bronchi  themselves  become  com- 
pressed ;  or,  it  is  re-absorbed,  so  that  the  cause 
of  aBgophony  is  removed.  The  latter  case  is 
indicated  by  a  return  of  the  natural  respiratory 
murmur  in  the  part,  and  a  sonorous  resonance 
on  percussion.  In  the  former  case,  all  sounds 
are  lost,  and  the  chest  sounds  uniformly  dulli 
except  in  a  small  space  close  to  the  vetebral 
column,  agamst  which  the  lung  is  compressed. 
The  effusion  is   sometimes  so  rapid  that  a  few 

*  M.  La^nnec  considers  that  another  cause  may  contribute  to  the  pro- 
duction of  aegophony  ;  namely,  the  flattening  of  the  bronchi  by  the  pres- 
sure of  the  effusion,  whereby  they  are  converted  into  little  reed  in- 
struments, all  set  a  piping  by  the  sound  of  the  voice.  Besides  that 
this  explanation  is  unnecessary,  I  must  object  also  that  it  is  untenable. 
The  reed  of  the  bassoon  and  hautboy  sounds  only  on  the  passage  of  air 
through  it,  and  did  the  flattened  bronchi  represent  it  in  this  instance,  the 
respiration,  and  not  the  voice,  should  make  them  sound. 


CAUSES    OF   ^GOPHONY.  121 

hours  duration  of  the  disease  may  produce  this 
state.  There  is,  however,  almost  always  one 
period  at  which  the  effusion  unites  the  condi- 
tions necessary  for  the  production  of  segophony  ; 
and  as  the  progress  of  the  disease  is  slow  or  ra- 
pid, the  duration  of  this  period  will  be  long  or 
short.  The  situations  in  which  it  is  most  fre- 
quently heard  may  be  included  in  a  band  about 
three  inches  broad,  running  from  below  the  infe- 
rior margins  of  the  scapula,  in  the  direction  of 
the  ribs,  to  the  sternum.  It  is  most  pure  in  the 
anterior  and  lateral  parts,  being  often  mixed 
with  a  natural  bronchophony  in  the  dorsal  re- 
gions. Sometimes,  however,  it  is  heard  in  nearly 
every  part  of  the  affected  side,  the  collection  of 
fluid  being  but  moderate.  This  universal  sego- 
phony never  continues  long,  unless  where  the 
lung  is  prevented  from  collapsing  before  the  in- 
creasing effusion,  by  old  adhesions  retaining  it 
at  a  little  distance  from  the  costal  pleura,  in  which 
case,  after  a  time,  the  respiratory  murmur  re- 
turns, the  pressure  not  being  sufficient  to  ex- 
clude totalty  the  air  from  the  vesicles.  Adhe- 
sions may,  in  other  ways,  modify  the  signs  of 
pleurisy.  Not  unfrequently  the  apex  or  subcla- 
vicular lobe  of  the  lung  adheres  closely  to  the 
costal  pleura  ;  an  effusion  can  here  never  destroy 
the  sound  of  respiration  under  the  clavicle,  and 
the  same  thing  may  occasionally  happen  in  other 
10 


122  ACUTE    PLEURISY. 

parts  of  the  lung ;  the  sound  of  the  respiration 
remaining,  however  great  the  effusion  in  those 
spots,  where  an  adhesion  protects  the  lung  from 
pressure. 

It  sometimes  happens  that  the  pleurisy  and 
its  effusion  are  quite  partial,  being  confined  to 
the  tissues  between  the  lobes,  or  to  a  part  on 
the  surface  by  adhesions.  The  accompanying 
pain  and  segophony,  will  generally  characterise 
these  circumscribed  pleurisies*.  If  these  symp- 
toms are  absent,  the  diagnosis  will  be  difficult, 
for  the  same  partial  absence  of  respiratory  mur- 
mur and  pectoral  resonance,  might  result  from 
other  causes. 

Whenever  the  effusion  is  abundant,  and  has 
been  rapidly  produced,  the  respiration  on  the 
healthy  side  will  become  puerile,  or  supplemen- 
tary. Now  as  the  sound  of  this  respiration  is 
sometimes  heard  on  the  diseased  side,  through  the 
liquid,  it  will  be  necessary  to  guard  against  the 
error  of  mistaking  it  for  a  faint  respiration  on 
that  side.  On  listening  attentively  to  the  sound, 
it  will  be  easy  to  perceive  that  it  increases  in  in- 
tensity as  the  ear  approaches  the  healthy  side, 
and  that  its  loudness  there  will  sufficiently  ex- 
plain its  source.      The  continuance  of  a  real, 

*  They  most  frequently  occur  in  phthisical  subjects,  being  excited 
sometimes  by  tubercles  and  sometimes  by  the  bursting  of  a  vomica  into  the 
pleura.  The  effusion  is  commonly  purulent,  and  may,  particularly  when 
interlobular,  be  mistaken  on  dissection,  for  an  abscess  of  the  lung. 


PHYSICAL    SIGNS.  123 

although  faint,  respiration,  in  a  space  of  about 
three  fingers  breadth  along  the  spinal  column, 
corresponding  with  the  compressed  lung,  will 
also  furnish  a  standard  of  comparison,  by  which 
the  other  sound  may  be  distinguished.  Besides 
these  tests,  the  ear,  by  practice,  acquires  the 
power  to  distinguish  at  once  a  sound  faint  by 
distance,  and  one  faint  in  origin. 

Another  important  physical  sign,  that  indi- 
cates an  abundant  effusion,  is  an  enlargement  of 
the  affected  side.  This,  although  when  mea- 
sured from  the  spinous  process  of  a  vertebra  to 
the  sternum,  seldom  exceeds  an  inch,  or  an  inch 
and  a  half,  is  very  obvious  to  the  eye  :  an  ob- 
server, placed  opposite  or  behind  the  patient 
as  he  sits  up,  or  stands  naked,  may  detect  the 
want  of  symetry  of  even  less  than  half  an  inch 
in  extent. 

Now,  when  the  disease  has  arrived  at  this 
state,  having  been  attended  with  more  or  less 
pain  of  side,  dry  cough,  dyspnoea  proportionate 
to  the  rapidity  of  its  course,  and  the  usual  febrile 
symptoms  of  acute  inflammation,  all  these  symp- 
toms may  disappear  ;  the  pain  and  cough  gone, 
the  pulse  nearly  natural,  the  appetite  returned, 
and  the  dyspnoea  but  slight,  felt  perhaps  only  on 
exertion  ;  in  short,  the  patient  may  appear  con- 
valescent, and  yet,  strange  to  sajr,  one  side  of 
his  chest  is  full  of  water  !     In  this  state,  if  he- 


124  ACUTE    PLEURISY. 

be  kept  quiet,  and  limited  to  a  strictly  antiphlo- 
gistic regimen,  there  will  be  the  symptoms  of  a 
slow  and  gradual  absorption,  which  we  shall 
presently  describe  ;  and  the  patient  may  in  time 
be  restored  to  real  health.  But  if,  relying  on 
his  sensations,  and  deceived  by  a  false  and 
illusory  feeling  of  health,  he  returns  to  an 
active  life,  with  a  full  and  generous  diet,  the 
consequences  may  be  disastrous.  Either,  the 
acute  disease  may  be  rekindled  from  its  smo- 
thered state,  excite  an  increase  of  circulation 
incompatible  with  the  crippled  state  of  the  or- 
gans, and  thus  produce  effusion  in  other  parts, 
and  consequent  suffocation  or,  the  pleuricy  may- 
continue  in  a  chronic  form,  perpetuating  the 
effusion,  becoming  a  part  of  the  habit  engen- 
dering tubercles,  or  other  accidental  produc- 
tions. Hence  organic  disease  will  run  its  re- 
sistless and  irremeable  course,  wearing  down 
the  strength  by  hectic,  and  wasting  the  body  by 
atrophy,  until  life,  scorning  to  dwell  in  such 
a  tenure,  ceases  to  hold  it  from  its  kindred 
earth. 

Such  may  be  the  direful  consequences  of 
relying  on  fallacious  general  symptoms.  Let 
us  seek  in  auscultation  and  percussion,  the 
beacon  to  warn  us  of  the  latent  danger,  and  to 
guide  us  to  the  employment  of  means  to  avert 
it.    The  absorption  of  the   fluid  is   indicated  by 


PHYSICAL    SIGNS.  125 

the  gradual  return  of  the  respiratory  murmur ; 
first,  in  those  points  where  it  had  persisted 
latest ;  afterwards,  in  others  ;  and  last  of  all  in 
the  parts  where  the  accumulation  had  begun.  It 
is  very  faint  at  first,  but  becomes  stronger  in 
time  ;  but,  general^,  a  very  long  period  is  re- 
quired to  bring  it  on  a  par  with  that  of  the 
healthy  side  :  sometimes  so  slow  is  the  absorp- 
tion, that  many  months  are  required  to  dissi- 
pate a  collection  of  fluid  that  was  formed  by  a 
pleurisy  of  a  few  days  duration.  In  other  in- 
stances, however,  the  absorption  is  nearly  as 
rapid  as  the  effusion,  and  in  these  cases  a  re- 
turning segophony  also  announces  the  diminu- 
tion. When  the  effusion  has  remained  long,  the 
segophony  seldom  returns  ;  for,  from  the  long 
continued  pressure,  the  bronchi,  in  which  it  is 
produced,  lose  their  elasticity,  and  do  not  im- 
mediately recover  a  sufficient  calibre  to  cause 
that  resonance  of  the  voice  which  constitutes 
bronchophony.  On  account  of  the  same  loss 
of  elasticity,  and  slow  restoration  of  aereal 
texture  in  the  lungs,  the  chest  never  recovers 
its  sound  on  percussion  proportionately  to  the 
return  of  the  respiratory  murmur.  Sometimes, 
for  causes  afterwards  to  be  mentioned,  the  af- 
fected side  remains  dull  as  ever,  after  the  com- 
plete absorption  of  the  liquid.  But  when  the 
complaint  has  been  of  short  duration  the  sono- 


126  ACUTE    PLEURISY. 

rousness  returns  perfectly,  although  more  slowly 
than  the  respiratory  murmur. 

In  the  double  pleurisy,  where  both  sides  are 
simultaneously  affected  (a  very  fatal  form  of 
the  disease),  the  indications  given  by  percus- 
sion are  less  certain  ;  for  both  sides  surrounding 
equally  ill,  the  standard  of  comparison  is  lost. 
But  auscultation  will  assist  us  to  detect  the 
cause  of  the  oppressing  dyspnoea,  which,  unless 
the  most  energetic  measures  are  employed,  may 
soon  end  in  suffocation. 

The  danger  in  acute  pleurisy  depends  on  the 
rapidity  and  quantity  of  the  effusion.  If  the 
segophony  continues,  it  is  a  proof  that  the  effu- 
sion is  moderate,  and  nearly  stationary,  which 
portends  an  easy  cure.  In  leucophlegmatic 
habits,  the  effusion  is  usually  very  abundant, 
and  its  absorption  slow  ;  hence  these  present  the 
most  unfavorable  cases.  After  the  system  has 
sustained  the  immediate  effects  of  the  effusion, 
a  transition  to  the  insidious  chronic  state  must 
be  the  source  of  apprehension,  and  this  as  long 
as  there  are  no  signs  of  a  re-absorption.  If,  from 
the  return  of  the  respiratory  murmur,  or  of 
segophony,  to  a  part  in  which  it  had  ceased,  it 
is  found  that  the  diminution  has  commenced  ; 
then  if  no  fresh  excitation  be  applied,  a  gradual 
cure  may  be  expected  with  confidence.  But  if 
after  the  cessation  of  the  acute  symptoms,   the 


TERMINATIONS.  127 

absorption  not  having  begun,  or  being  arrested 
in  its  course,  a  slight  fever  rekindles,  generally 
with  evening  exacerbations,  attended  with  more 
or  less  cough  and  mucous  or  mucopurulent  ex- 
pectoration, then  it  is  to  be  feared  that  the  dis- 
ease has  taken  the  inveterate  and  intractable  ha- 
bits of  the  chronic  disease,  and  the  prognosis 
becomes  so  much  the  more  unfavourable. 

Let  us  bestow  some  attention  on  the  changes 
that  accompany  the  different  terminations  of 
pleurisy. 

The  serous  effusion  is  not  the  only  product 
of  the  pleuritic  inflammation,  although  it  is  the 
only  one  that  is  indicated  by  physical  signs.  A 
plastic  or  coagulable  lymph  is  at  the  same  time 
exsuded  by  the  inflamed  membrane,  and  becomes 
the  basis  of  a  variety  of  products.  Now  as  this 
takes  in  different  forms,  according  to  the  modi- 
fications of  inflammation,  it  will  be  useful  to  en- 
quire whether  this  variety  depends  on  unknown 
causes,  or  whether  it  be  not  referrible  to  some 
known  pathological  law. 

The  secretory  action  of  the  vessels  of  a  part 
in  health  is  twofold  ;  1.  the  action  of  assimilation 
or  nutrition,  by  which  the  tissue  is  perpetuated 
in  its  kind,  and  preserved  notwithstanding  the 
operation  of  an  opposite  power,  absorption  ;  and 
2.  external  secretion,  or  action  by  which  some 
parts  of  the  blood  are   separated   from   or  out 


128  ACUTE    PLEURISY. 

of  the  tissue.  The  first  is  the  more  perfect  act 
of  living  structure,  varying  in  the  different  ele- 
mentary textures  of  the  body,  but  always  pre- 
serving their  individual  identity.  The  latter,  in 
its  simplest  kind,  is  little  more  than  a  mechani- 
cal transudation  of  the  more  watery  parts  of 
the  blood,  such  is  the  secretion  of  serous  and 
cellular  membrane  ;  but  when  modified  by  com- 
plicated structure  and  vital*  energy,  the  pro- 
duct of  this  secretion  is  often  more  peculiar  and 
characteristic  than  that  of  the   assimilatory  of 

*  Shall  I  say  nervous  ?  So  the  analytic  experiments  of  Mr.  Brodie,  Dr. 
Philip,  &c.  seem  to  indicate  ;  but  I  think  with  Dr.  Alison,  not  yet  in  a 
manner  sufficiently  decisive.  To  clear  this  matter  labour  and  thought  yet 
are  wanted. 

"  Nil  sine  magno, 
"  Vita  labore  dedit  mortalibus." 

Still  let  us  guard  against  the  error  of  considering  the  term  vital  as  ex- 
planatory, or  as  implying  an  ultimate  thing,  not  to  be  analyzed  or  resolv- 
ed into  simpler.  I  would  rather  employ  it  as  a  generic  term,  comprehend- 
ing not  only  the  unknown  power  operating  in  the  living  body,  and  hitherto 
unexplained  by  any  physical  laws  ;  but  also  the  operation  of  physical 
laws  through  a  mechanism  or  organization,  peculiar  to  living  bodies.  The 
progress  of  physiology,  which  has  already  transferred  many  living  actions 
from  the  former  to  the  latter  class,  may  ultimately  penetrate  the  mist  that 
obscures  the  remaining  terra  incognita  of  vitality,  and  find  there  nothing  so 
unearthly  as  not  to  be  reducible  to  the  chart  of  animal  physics.  JBe  it  un- 
derstood, I  speak  here  of  organic  actions  only.  The  sensorial  or  animal 
powers  require  a  distinct  consideration,  and  then  appear  like  the  proper- 
ties of  matter,  too  simple  for  analysis  ;  like  geometrical  lines  or  points,  too 
elementary  to  admit  of  definition.  Any  explanation,  therefore,  applied  to 
these  can  be  but  sophistry,  for  if  mental,  it  would  be  to  argue  in  a  circle,  if 
material,  ignotum  in  ignotius, 

"  Nee  scire  fas  est  omnia." 


EFFECTS  OF  INFLAMMATION  ON  TISSUES.   129 

the    same    texture :    this    is    instanced   in    the 
kidneys,  liver,  and  other  excretory  organs. 

Such  are  the  healthy  secretory  functions  of  all 
tissues.  Now  let  the  vascular  action  of  the 
part  be  increased  in  different  degrees.  The  first 
effect  will  be,  an  increase  in  the  external  secre- 
tion ;  in  great  measure  the  mechanical  result  of 
an  augmented  flow  of  blood.  The  same  degree 
of  increase  will  also  in  time  affect  the  slower 
process  of  nutrition,  causing  simple  hypertro- 
phy, or  increase  of  natural  substance.  These 
changes,  although  frequently  produced  by 
disease,  do  not  differ  in  nature  from  the  physio- 
logical phenomenon  of  growth.  On  a  further 
increase  of  vascular  action,  however,  the  effect 
becomes  more  peculiar  to  a  pathological  state. 
Besides  a  greater  change  in  the  external  secre- 
tion, the  tissue  itself  becomes  more  or  less 
thickened  and  altered,  being  at  first  softened, 
but  if  the  cause  continue  long,  afterwards  indu- 
rated ;  the  one  being  the  effect  of  acute,  and 
the  other  of  chronic  inflammation.  Now  what 
are  these  but  modifications  of  the  nutritive  or 
assimilatory  secretions  ?  It  is  augmented  ;  new 
matter  is  deposited  in  the  tissue,  first  in  a  liquid 
state,  diminishing  its  molecular  cohesion;  hence 
the  softening ;  the  cause  continuing,  and  no 
re-absorption  taking  place,  the  new  matter,  ac- 
cording to  its   accustomed   process,    becomes 

17 


130  ACUTE    PLEURISY. 

solid,  and  uniting  in  firm  molecular  adhesion 
with  the  tissue,  increases  its  solid  substance : 
hence  the  induration.  Now  this  change  of 
nutrition  differs  from  simply  hypertrophy,  or 
growth,  in  the  more  condensed  arrangement  of 
the  solid  particles,  and  presents  the  first  in- 
stance of  structural  disease,  peculiarly  patholo- 
gical. Let  the  vascular  action  be  yet  increased 
further,  there  will  be  an  overflow  of  the  nutri- 
tive secretion,  which,  no  longer  confined  to  the 
texture,  will  now  become  external,  and  will  be 
effused  with  the  liquid  secretion,  in  forms  vary- 
ing according  to  the  degree  of  inflammation, 
and  changes  already  induced.  The  matter 
thus  effused  is  albumen  or  fibrine,  the  coagulable 
parts  of  the  blood  ;for  as  Berzelius,  and  Prevost 
and  Dumas  have  shewn,  these  are  but  varieties 
of  the  same  substance.  Enough  in  the  abstract : 
— now  let  us  apply  these  general  pathological 
laws  to  the  case  before  us. 

The  pleura  is  a  simple  lamina  of  membrane, 
so  thin,  and  of  context  so  simple,  that  it  is 
scarcely  susceptible  of  thickening.  As  soon, 
therefore,  as  it  is  sufficiently  inflamed  to 
augment  the  nutritive  secretion  of  the  ves- 
sels, this  soon  overflows  outwardly  ;  and  with 
the  increased  external,  or  serous  exhalation,  an 
albuminous  exsudation  takes  place  on  the  surface 
of  the  membrane.     This  exsudation  is  the  basis 


ADHESIONS.  131 

of  all  the  factitious  membranes,  accidental  pro- 
ductions, and  diseased  formations  found  in  the 
cavities  of  the  pleura*.  Let  us  now  examine 
how  these  varied  products  result  from  different 
degrees  or  modifications  of  inflammatory  ac- 
tion. 

In  the  acute  form  of  pleurisy,  the  inflamma- 
tor}'  orgasm  is  intense,  and  the  nutritive  secre- 
tion increased  to  the  utmost  ;  the  albuminous 
exsudation  is  abundant,  easily  organizable,  and 
capable  of  as  high  vitality  as  the  membrane 
that  secreted  it.  In  fact,  the  vessels  under  the 
influence  of  inflammation  produce,  at  once, 
what  in  health  they  are  required  to  do  slowly, 
and  to  supply  decay — the  materials  of  their  own 
membrane.  The  simultaneous  exhalation  of 
serum  separates  the  lymph  thus  thrown  out 
into  thin  laminae,  and  these  becoming  vascular, 
in  the  manner  described  by  Sir  Everard  Home, 

*  I  consider  inflammation  of  a  serous  membrane  to  be  the  most  simple 
of  any.  In  more  complicated  structures,  its  varied  effects  arise  from  the 
difference  of  structure.  Why  does  an  inflamed  mucous  membrane  throw 
out  pus  and  not  coagulable  lymph  ?  The  reason  is  obvious.  Its  inter- 
nal or  nutritive  secretion  being  increased  beyond  the  degree  causing  simple 
hypertrophy,  an  interstitial  effusion  takes  place,  which  causes  a  thickening 
of  the  membrane,  and  mechanically  restrains  its  further  effusion,  so  that 
the  inflammatory  orgasm  continues  ;  the  external  overflow  of  the  nutritive 
matter  will  be  in  a  disintegrated  form,  in  separate  particles,  or  globules, 
and  far  less  susceptible  of  consolidation  and  organization.  It  would  be 
easy  to  trace  other  varieties  to  analogous  differences  of  structure ;  but  the 
"  certi  denique  fines"  of  this  work  forbid  my  taking  such  an  excursion. 


132  HEMORRHAGIC    PLEURISY. 

are  further  perfected  into  a  number  of  new 
serous  membranes,  forming  bands  of  adhesion 
between  the  pleura  that  produced  them.  These 
adhesions,  the  result  of  a  frankly  acute  inflam- 
mation, are  so  exceedingly  common,  that  it  is 
rare  to  open  a  body  without  them.  Being  loose 
and  mobile,  they  appear  to  produce  little  or  no 
inconvenience  or  impediment  to  the  respiratory 
motions. 

It  is  different  with  another  modification  of 
the  disease,  which  Laennec  has  denominated 
hemorrhagic  pleurisy.  The  albuminous  effu- 
sion has  then  mixed  with  it  more  or  less  of  the 
colouring  matter  of  the  blood.  Now  this  im- 
pedes the  process  of  organization,  for  the  co- 
louring matter  in  no  way  contributes  to  the 
formation  of  texture,  and  must  be  absorbed  be- 
fore the  organization  can  be  perfected.  As  the 
new  product  is  of  slow  generation,  so  is  its  vi- 
tality of  a  lower  degree  ;  the  excitation  or  or- 
gasm of  the  vessels  having  been  much  dimi- 
nished before  it  could  be  extended  to  the  new 
sphere  of  action,  the  matrix  of  the  new  tissue. 
Hence  there  is  produced  not  a  new  serous  mem- 
brane, but  one  of  a  fibrous  or  fib ro- cartilaginous 
texture,  of  inferior  vitality,  and  wanting  the 
soft  and  yielding  mobility  of  the  serous  tissue  ; 
and  this  character  in  a  less  degree  extends  to 
adhesions  formed  by  pleurisies,  slow  in  progress 


TERMINATION.  133 

that  are  not  hemorrhagic  Now,  what  will  be 
the  consequences  of  the  formation  of  such  a 
membrane  ?  The  lung  will  be  bound  down  by 
it  in  the  compressed  state  to  which  it  has  been 
reduced  by  the  accumulation  of  the  liquid  effu- 
sion, which,  in  these  cases,  is  always  abundant 
and  of  long  duration.  The  liquid  being  dimi- 
nished by  absorption,  the  lung,  thus  restrained, 
can  but  partially  recover  its  expanded  state  ;  and 
one  of  two  things  must  take  place  to  fill  the  va- 
cuum left  by  the  retroceding  effusion  :  either, 
the  thoracic  parietes  will  be  drawn  inwards  into 
close  contact  with  the  diminished  lung  ;  or,  the 
place  of  the  effusion  will  be  occupied  by  an  aeri- 
form exhalation.  The  first  is  the  most  common 
case,  and  constitutes  the  contraction  of  the 
chest  so  well  described  by  Laennec. 

In  a  subject  thus  affected,  the  contraction  is 
discovered  at  once  by  the  eye,  and  may  be 
proved  by  a  measurement,  compared  with  the 
healthy  side.  The  ribs  are  drawn  closer  toge- 
ther, the  shoulder  lower,  and  the  muscles  ap- 
pear less  prominent  than  on  the  healthy  side. 
When  the  contraction  is  considerable,  the  per- 
son leans  a  little  to  the  affected  side,  which 
causes  something  like  a  limping  in  his  gait. 
The  chest  having  on  this  side  lost  the  elastic 
freedom  of  equal  tension,  is  no  longer  resonant 


134  EFFECTS    OF    PLEURISY. 

on  percussion.  The  sound  of  respiration  is, 
however,  preserved  with  a  diminished  intensity, 
except  in   the  inferior  parts,  where  it  is  gene- 

rallv  obliterated*. 

%> 

The  general  symptoms  of  hemorrhagic  pleu- 
risy are  frequently  not  well  marked,  and  it 
is  always  very  long  in  its  progress  towards 
cure.  Several  months  are  required  for  the 
dispersion  of  the  effusion,  and  the  full  contrac- 
tion of  the  chest.  This  being  effected,  the 
new  fibro-cartilaginous  membranes  of  the  costal 
and  pulmonary  pleurae  come  into  contact,  and 
as  they  are  not,  as  serous  surfaces,  adapted  for 
mutual  friction,  by  an  augmentation  of  the  nu- 
tritive secretion  of  their  vessels,  a  gelatinous 
matter  is  deposited  between  them,  which,  in 
time,  becomes  a  bond  of  union,  consisting  of 
fibro-cartilage  of  lower  vitality,  or  even  of  real 
cartilagef. 

*  This  is,  of  course,  because  the  inferior  lobes  of  the  lungs  are  so 
much  compressed  that  they  are  perfectly  impermeable  to  the  air.  They 
appear,  on  dissection,  flaccid,  like  a  uniform  muscular  tissue,  sometimes 
red   or  livid,  and  sometimes  of  a  light  fawn  colour. 

f  It  is  in  this  middle  lamina  that  the  ossific  process  frequently  ope- 
rates. In  one  instance  I  have  seen  this  exemplified  in  the  formation  of 
a  bony  lamina,  of  considerable  thickness  on  each  side  of  the  lung,  and 
covering  it  like  a  cuirass.  The  natural  tendency  of  cartilage  to  ossifica- 
tion, and  the  acceleration  of  this  process  by  inflammation,  so  sagaciously 
pointed  out  and  beautifully  described  by  M.  Andral,  in  his  works  and 
lectures,  may  be  comprehended  in  the  view  I  have  attempted  to  give  of 
"  the  effects  of  increased  determination  of  blood  on  the  different  secretory 
power  of  vessels. 


CONTRACTION    OF   THE    CHEST.  135 

This  may  be  considered  a  cure  for  persons 
thus  affected,  although  they  have  a  shorter 
breath  than  others,  labour  under  no  habitual 
dyspnoea.  Catarrhs,  and  other  affections  imped- 
ing respiration,  will  be  more  severe  in  their 
effects  on  such  subjects,  as  they  have  less  room 
for  abridgement  of  the  function.  On  the  other 
hand,  they  may  be  considered  more  exempt 
from  pleuritic  attacks  in  future,  as  the  gluing 
together  of  the  pleurae  renders  the  pleuritic 
effusion  impossible  on  that  side. 

I  have  mentioned  another  event  of  the  con- 
finement of  the  lung  by  a  fibro-cartilaginous 
membrane,  namely,  the  filling  up  the  space  left 
by  the  effusion  with  an  aeriform  exhalation. 
This  mode  of  termination,  although  not  no- 
ticed by  Laennec  or  any  other  author,  has 
fallen  under  my  own  observation;  and,  1  be- 
lieve, is  likely  to  occur  in  most  cases  where  the 
haemorrhagic  pleuris}'  is  partial,  or  confined  by 
ancient  adhesions.  A  partial  cavity  is  formed 
by  the  effusion,  which,  on  its  re-absorption, 
cannot  be  filled  by  any  contraction  of  the 
thoracic  parietes.  It  therefore  becomes  filled 
with  gases  with  which  the  animal  fluids  abound. 
This  case  is  different,  it  must  be  remarked, 
from  those  described  by  Laennec,  in  which  the 
pneumothorax  is,  as  it  were,  active,  and  in 
which    the  gases  themselves  (perhaps  evolved 


136  CHRONIC    PLEURISY. 

by  the  decomposition  of  the  pleuritic  effusion), 
and  not  a  fibro-cartilaginous  membrane,  con- 
tinue to  keep  down,  by  pressure,  the  reduced 
lung.  The  pneumothorax  is  here  the  disease, 
but,  in  the  former  case,  a  consequence  of 
the  cure.  I  shall  return  to  these  cases  after- 
wards. 

Let  us  now  examine  the  effect  of  a  third  de- 
gree or  modification  of  pleuritic  imflammation, 
constituting  what  is  called  chronic  pleurisy. 
The  inflammatory  excitation,  although  suffi- 
cient to  cause  an  overflow  of  the  nutritive  se- 
cretion, is  not  adequate  to  extend  itself  by  vas- 
cular communication  with  the  organizable  ma- 
terials thus  thrown  out :  these  being,  therefore, 
retained  by  no  bond  of  union,  become,  in  suc- 
cession, detached  from  the  pleura  in  small 
flakes,  and  mixing  in  great  abundance  with  the 
serous  effusion,  constitute  the  liquid  of  empy- 
ema. 

Empyema,  then,  is  produced  by  a  chronic 
inflammation  of  the  pleura  ;  and  is  neither  the 
result  of  the  suppuration  of  the  lung,  as  was 
formerly  supposed,  nor,  in  fact,  is  it  formed  by 
real  pus.  The  difference  is,  however,  less  than 
this  description  would  at  first  suggest,  since 
both  consist  of  albuminous  globules  floating  in 
a  serum ;  but  in  the  liquid  of  empyema  the 
globules  are    united  in    small  flakes,    and   the 


EMPYEMA,  137 

serum  is  more  abundant,  both  of  which  pecu- 
liarities may  be  explained  by  the  structure  of 
the  membrane  that  secretes  it.  In  its  physical 
signs,  chronic  pleurisy  does  not  materially  differ 
from  the  acute  disease.  The  effusion  is  recog- 
nised by  the  dull  sound  on  percussion,  total 
absence  o  f  the  respiratory  murmur,  and  the 
enlargement  of  the  affected  side.  ^Egophony 
is  rarely  present ;  for'  generally  the  disease  is 
either  engrafted  on  an  acute  one  ;  or,  if  idio- 
pathically  chronic,  commenced  so  insidiously, 
that  the  effusion  has  exceeded  the  segophonic 
degree  before  it  attracts  attention.  The  gene- 
ral symptoms  are  usually  such  as  practitioners 
in  this  country  would  consider  indicatory  of 
phthisis,  and  joined,  as  it  usually  is,  with 
chronic  catarrh,  and  sometimes  purulent  expec- 
toration, it  is  impossible,  without  the  aid  of  the 
physical  signs,  to  distinguish  between  the  two 
diseases. 

In  fatal  cases,  which  Laennec  rates  at  the 
proportion  of  a  half,  the  last  stage  presents  com- 
plications with  peritonic  and  gastric  disorders, 
and  the  patient  dies  in  a  state  of  extreme  ema- 
ciation. Where  the  predisposition  exists, 
chronic  pleurisy  often  excites  the  secretion  of 
tubercular  matter,  and  perhaps  also  the  forma- 
tion of  miliary  tubercles  in  the  pulmonary 
tissue.  It  is  by  such  peculiar  predispositions 
18 


138  PLEUROPNEUMONIA. 

or  diatheses*,  that  the  products  of  inflammation 
or  increased  vascular  action  are  changed  from 
new  membranes  and  pus,  to  scirrhous,  cere- 
briform,  and  tubercular  formations.  An  in- 
crease in  the  nutritive  secretion  must  be  the 
basis  of  all  these  new  productions  ;  the  manner 
in  which  this  is  modified  by  peculiar  constitu- 
tion is  involved  in  the  mystery  of  secretion ; 
but  the  increase  is  certain.  Now,  for  an  in- 
creased secretion,  there  must  be  an  increased 
determination  of  blood.  Does  this  amount  to 
inflammation  ?  I  answer  by  another  question, 
which  proves  the  logomacheia— What  is  in- 
flammation ? 

Section  II. — Pleuropneumonia. 

It  very  frequently  happens  that  pneumonia 
is  attended  with  some  inflammation  of  the 
pleura ;  and  again,  in  plurisy,  there  is  often  an 
extension  of  inflammation  to  the  pulmonary 
parenchyma.  This  complication,  instead  of 
presenting  a  more  aggravated  case,  rather,  as 
M.  Laennec  remarks,  mitigates  the  severity  of 
both  diseases  ;    and    this  from  a  cause  purely 

*  Flimsy  and  unmeaning  words  these,  and  yet  necessary  in  our  igno- 
rance. The  study  of  pathology  has  done  much,  and  will  do  more  for  the 
improvement  of  medical  science  ;  but  when  shall  that  propitious  day  come, 
when  the  art  of  medicine  shall  cease  to  be  a  hovel  of  disjointed  material  ? 
when — with  foundation  in  firm  nature,  laid,  built  and  cemented  by  sci- 
ence— shall  it  really  prove  the  temple  of  Hygeia,  a  certain  refuge  from  the 
tempest  of  disease  ? 


PHYSICAL    SIGNS.  139 

mechanical  The  pressure  exerted  by  the 
pleuritic  effusion  moderates  the  inflammatory 
action  in  the  lung  ;  and,  again,  the  lung,  in  some 
degree  consolidated  by  the  inflammatory  pro- 
cess, not  yielding  to  the  encroaching  effusion, 
sets  limits  to  its  accumulation.  If,  however, 
the  intensity  of  a  pneumonia  is  diminished  by 
a  cotemporaneous  pleurisy,  its  duration  is  pro- 
bably prolonged ;  for  the  process  of  resolution 
is  always  much  slower  in  this  than  in  the  simple 
ease.  This  is  because  the  interstitial  effusion 
is  more  solid,  and  less  mixed  with  the  serous 
exhalation  produced  by  common  inflammation, 
and  which  cannot  but  assist  in  the  discussion  of 
the  denser  products.  On  the  other  hand  a 
pleurisy,  coinciding  with  pneumony,  will  be  of 
easier  and  speedier  cure,  inasmuch  as  the  effu- 
sion is  less  abundant  *. 

The  signs  of  pleuropneumony  are,  as  may  be 
expected,  a  combination  of  the  signs  of  pneu- 
monia and  pleurisy.  The  crepitant  rhonchus 
will  be  heard  in  all  those  parts  of  the  lung,  af- 
fected with  inflammation,   that  are   not  pushed 

*  It  is  by  inflammation,  thus  modified  by  pressure,  that  is  produced 
that  change  in  the  lung,  called  by  Laennec  carnification.  The  tissue  of 
the  lung  in  this  state  has  the  colour  and  consistence  of  flesh,,  is  no  longer 
crepitant,  and  presents  no  traces  of  the  vesicular  structure.  The  supurla- 
tive  stage  is  scarcely  ever  observed  in  it  ;  M.  Laennec  has,  in  a  few  in- 
stances, remarked  a  kind  of  yellow  carnification,  perhaps  a  modification 
of  the  third  stage. 


140  PLEUROPNEUMONIA. 

away  too  far  by  the  effusion.  It  may,  therefore, 
be  looked  for  at  the  root  of  the  lung,  and  all 
round  the  middle  regions  of  the  thorax  ;  and  it 
may  sometimes  be  heard  in  other  parts.  Again, 
t  he  segophony,  the  sign  of  the  pleurisy,  is 
commonly  to  be  found  at  the  root  of  the  lung  ; 
and  here  it  is  generally  combined  with  a 
noisy  bronchopony  proceeding  from  the  large 
bronchial  ramifications.  This  combination  of 
aegophony  and  bronchophony  M.  Laennec  com- 
pares to  the  squeaking  voice  of  punchinello. 
The  comparison  is  pretty  exact,  but  not  quite 
adequate  to  represent  the  impression.  Besides 
the  punchinello  voice,  composed  of  a  buzz  and 
a  squeak,  there  is  a  tremulous  or  vibratory 
character  in  the  sound,  which  seems  alternately 
to  approach  and  recede  from  the  ear  in  sudden 
jerks.  These  signs,  as  they  usually  continue 
throughout  the  disease,  render  it  very  easy  of 
recognition. 

The  occurrence  of  extensive  peripneumony 
with  copious  pleuritic  effusion  is  compafltively 
rare.  It  is  more  common  that  one  disease  has 
the  predominance,  and  is  attended  only  with 
a  slight  degree  of  the  other.  Inflammation 
occupying  part  of  a  lung,  is  frequently  extend- 
ed outwardly  to  the  pleura,  which  becomes 
covered  at  that  point  with  a  thin  coating  of 
coagulable  lymph,   and  secretes  a  seropurulent 


VARIETIES. SIGNS.  141 

liquid ;  and  it  is  a  remarkable  fact  that  lymph 
is  often  effused  also  by  the  corresponding  point 
of  the  costal  pleura,  the  inflammation  being 
propagated  by  contiguity.*  The  segophony 
on  the  one  hand,  and  the  crepitant  rhonchus 
on  the  other,  will  easily  distinguish  such  a  case. 
But  if  the  whole  of  a  lung  be  inflamed,  and 
converted  into  a  solid  mass,  although  there 
be  no  liquid  effusion  in  the  pleura,  the  only 
sign  that  will  distinguish  the  case  from  that  of 
a  copious  pleuritic  effusion,  is  a  more  noisy  and 
almost  pectoriloquous  bronchophony  at  the 
root  of  the  lung.  But  if  this  case  has  been  ob- 
served in  its  progress,  the  characters  of  the 
first  stage  of  pneumonia  must  have  sufficiently 
announced  its  nature. 

Pleurisy  is  sometimes  accompanied  by  a  cir- 
cumscribed, and  even  lobular  pneumonia,  mo- 
dified in  the  manner  above  described.  This  in- 
flammation will  generally  be  announced  in  some 
corresponding    point  of    the    chest,   where  the 

*  This  is  one  instance,  out  of  many  of  the  same  kind,  which  seem  to 
indicate  that  the  assimilatory  power  of  inflammation,  or  perhaps,  even 
its  proximate  cause,  is  of  a  nature  more  mohile  and  subtle  than  can  be 
explained  from  any  known  modification  of  vascular  action.  The  Brous- 
saians  resort  to  the  term  irritation,  less  exceptionable  only  because  more 
vague  :  "  Res  non  verba  qiueso."  These,  and  many  other  phenomena 
seem  to  mc  to  approximate  certain  vital  properties  to  electrical  or  gal- 
vanic influence.  Such  an  explanation  must,  however,  yet  be  in  the  un- 
certainty of  remote  prospect :  we  have  not  yet  arrived  at  the  ground  of 
its  proofs. 


142  HYDROTHORAX. 

stratum  of  pleuritic  effusion  is  thin,  by  the 
crepitant  rhonchus.  In  short,  it  is  easy,  from 
a  knowledge  of  the  pathology  of  pleuropneu- 
monia, to  predicate  all  the  varieties  in  its  phy- 
sical signs,  as  they  indicate  more  of  a  pleuritic 
or  of  a  pulmonary  inflammation. 

Section  III. — Hydrothorax. 

It  was  formerly  the  common  opinion,  and  is 
even  now  believed  by  many,  that  idiopathic 
hydrothorax  is  a  very  common  disease,  pro- 
ducing a  formidable  array  of  symptoms,  and 
often  causing  death  by  suffocation.  In  these 
late  years  the  erroneousness  of  this  opinion 
has  been  shewn  ;  on  the  one  hand,  by  the 
study  of  pathological  anatomy,  which  has  dis- 
covered, in  the  supposed  cases  of  simple  hydro- 
thorax,  extensive  organic  causes  of  disease, 
without  any  effusion ;  and,  on  the  other  hand, 
by  auscultation  and  percussion,  which  have  not 
only  proved  the  same  during  life,  but  have  like- 
wise taught  us  that  hydrothorax,  when  it  does 
exist,  can  have  but  a  very  small  share  in  pro- 
ducing the  symptoms  that  have  hitherto  been 
ascribed  to  it. 

In  fact,  simple  and  idiopathic  hydrothorax, 
or  dropsy  of  the  pleura,  causes  but  one  general 
symptom,  dyspnoea,  and  this  to  a  very  slight 
degree,  unless  the   dropsical   effusion  be  very 


PHYSICAL    SIGNS.  143 

abundant,  and  of  sudden  formation.  A  symp- 
tomatic hydrothorax  is  sometimes  produced  a 
short  time  before  the  fatal  termination  of  or- 
ganic diseases  of  the  viscera  ;  and,  excepting 
dyspnoea,  these  cases  are  attended  with  no 
symptom,  that  is  not  frequently  present  in  the 
same  diseases,  terminating  without  hydrothorax. 
In  short,  I  need  only  refer  to  the  history  that 
I  have  given  of  pleurisy, -to  show  how  very 
slight  and  uncertain  are  the  symptoms  of  even 
an  abundant  effusion  in  the  pleural  cavity.  The 
physical  signs  are  the  only  certain  tests  of  its 
presence  ;  and,  in  the  present  instance,  they 
will  be  equally  infallible  :  I  need  scarcely  ob- 
serve, that  they  do  not  differ  from  those  of  the 
pleuritic  effusion.  An  idiopathic  hydrothorax 
is  to  be  distinguished  from  this  latter  case  by 
the  absence  of  fever  and  other  constitutional 
symptoms,  peculiar  to  pleurisy. 

Symptomatic  hydrothorax  will  combine  with 
the  common  signs  of  pleuritic  effusion,  those 
of  whatever  organic  disease  it  is  the  conse- 
quence ;  and  this  will  generally  be  found  to  be 
some  lesion  of  the  circulatory  apparatus,  by 
which  its  function  is  extensively  impeded.  La- 
ennec  states  that  it  scarcely  ever  supervenes 
earlier  than  a  few  days  before  the  fatal  ter- 
mination of  such  diseases,  and  may,  there- 
fore,  be  considered  the,  immediate    harbinger 


144  PNEUMOTHORAX. 

of  death,  the   agony   of  which  it  increases  by 
dyspnoea. 

Section  IV. — Hemothorax. 

Besides  in  the  case  of  hemorrhagic  pleurisy, 
formerly  mentioned,  blood  may  be  effused  into 
the  sac  of  the  pleura  from  a  wound,  by  the  rup- 
ture of  an  aneurism,  by  pulmonary  apoplexy,  and 
by  a  passive  transudation.  As  long  as  this 
blood  remains  liquid,  it  must  produce  the  same 
effects  as  we  have  described  of  serum  in  the 
same  situation.  When  coagulated,  it  would  ren- 
der obtuse  the  sound  of  percussion,  and  diminish 
the  respiratory  murmur  in  proportion  to  its 
quantity  ;  and  might,  perhaps,  produce  broncho- 
phony, but  not  segophony,  for  that,  as  we  have 
seen,  is  the  result  only  of  a  liquid  effusion. 
Some,  therefore,  of  its  physical  signs  would  ena- 
ble the  practitioner  to  distinguish  pneumothorax 
from  other  solid  or  liquid  formations  in  the  tho- 
racic cavity. 

Section  V. — Pneumothorax. 

Pneumothorax,  or  a  collection  of  air  in  the 
pleural  sac,  may  be  either  active  or  passive. 
It  is  active  when  the  air,  whether  exhaled  from 
the  pleura,  or  generated  by  the  decomposition 
of  a  liquid  effusion,  by  the  force  of  its  own  ac- 
cumulation, presses  back  the   lung  towards  its 


VARIETIES.  145 

points  of  attachment.  It  is  passive  when  the 
air,  either  entering  by  a  communication  with 
the  external  air,  supplies  the  place  of  the  lung 
diminished  by  its  own  collapse,  or  generated 
within  the  sac,  fills  up  a  cavity  left  by  a  re- 
absorbed collection  of  liquid,  after  those  cases 
of  pleurisy  in  which  the  lung  is  bound  down 
by  a  fibrocartilaginous  membrane,  and  the  pa- 
rietes  of  the  chest  cannot  by  their  collapse  obli- 
terate the  cavity.  This  division  includes  and 
defines  all  the  varieties  of  pneumothorax. 

The  most  common  of  all  these  is  that  variety 
of  the  passive  form  which  results  from  a  fistu- 
lous communication  between  the  pleural  sac 
and  the  bronchi.  This  communication  is  usu- 
ally caused  by  the  tubercular  ulceration  in 
phthisis,  extending  itself  through  the  pleura. 
The  pneumothorax,  in  this  case,  is  usually  ac* 
companied  by  some  pleuritic  effusion,  excited 
by  the  entrance  of  softened  tuburcle  or  some 
extraneous  matter  from  the  fistula.  Active 
pneumothorax  is  of  rare  occurrence,  and  is  ge- 
nerally like  s37mptomatic  hydrothorax,  with 
which  it  is  sometimes  conjoined,  the  precursor 
of  death.  It  sometimes  accompanies  the  pleurisy 
excited  by  the  bursting  of  a  tuberculous  vomica 
into  the  pleura,  where  there  is  no  communica- 
tion with  the  bronchi  *. 

*  Louis  Rech.  sur  la  Phthisic. 

19 


146  PNEUMOTHORAX 

The    physical  signs  of  pneumothorax   are  very 
characteristic,  but  they   vary  considerably,  ac- 
cording to  the  form  of  the  disease.     In  all    the 
varieties,  but  particularly  in  the   active   kinds, 
the  tympanic  sound  of  the  chest  on    percussion 
is  increased,  so  that  the  diseased  sounds  as  well 
as,  or  even  better  than,  the  healthy  side  ;  the  rea- 
son   is    too  obvious    to    require     explanation. 
Hence  percussion  alone  may  be  a  source  of  error. 
Auscultation  will  correct  it,  and  a    certain  diag- 
nosis may   be  deduced    from    their    conjoined 
indications.     The  sound  of   respiration  will,   by 
the  pressure  and    interposition  of  the  air  in  the 
thoracic  cavity,  be   obliterated  fn  all    parts  ex- 
cept at  the  root  of  the  lung  ;  whereas,  in   early 
pleuritic  effusion,  it  may  still  be  heard.     Where, 
therefore,  the  chest  is  sonorous  on    percussion, 
and  yet  no   respiratory  sound    heard,    it  may 
safely  be  concluded  that  a  pneumothorax  exists. 
The  only  case  in   any   degree   approaching  to 
this  is  that  of  emphysema,  but  in  this  the   sound 
of  respiration  is   only   diminished,   not  entirely 
destroyed,    and   the  presence  of  an  occasional 
sibilation,  and  still  more  certainly  its   pathogno- 
monic sign,  dry   crepitation,   will  clearly   distin- 
guish this  disease.    Add  to  these,  that  the  sound 
of  respiration,  absent  in  other  parts,  remains  au- 
dible at  the  root  of  the   lung  in  pneumothorax, 
while  no  such   difference  is   observable  in  em- 


WITH    LIQUID    EFFUSIOX.  147 

physema.  In  pneumothorax,  as  in  pleuritic  ef- 
fusion, the  lung  is  sometimes  retained  in  contact 
with  the  chest  here  and  there  by  adhesions  ;  and 
at  these  points  the  respiratory  murmur  is  not 
obliterated.  Hence  the  necessity  of  examining 
every  part  of  the  thoracic  surface  before  a  cor- 
rect knowledge  can  be  attained  of  the  physical 
state  of  the  organs  contained  in  it. 

When  there  is  a  collection  of  both  liquid  and 
air  in  the  pleura,  the  chest  is  of  course  less  so- 
norous on  percussion  than  in  simple  pneumo- 
thorax ;  but  then  the  inferior  parts  sound  very 
dull,  while  those  above  emit  a  clear  sound,  and 
the  transition  from  one  to  the  other  is  often  very 
abrupt.  On  practising  percussion  too,  in  diffe- 
rent postures,  the  presence  of  a  liquid  will  be 
discovered  by  its  rendering  the  sound  obtuse 
always  in  the  most  dependent  parts  of  the  tho- 
rax ;  while  the  air,  rising  to  the  superior  parts, 
gives  them  a  tympanitic  resonance. 

It  is  in  these  <:ases  that  the  presence  of  the 
liquid  becomes  frequently  perceptible  to  the  ear 
by  the  sound  of  gurgling  or  fluctuation,  into 
which  it  is  thrown  by  the  respiratory  move- 
ments, or  any  sudden  motion  applied  to  the 
thorax.  Here  it  is,  therefore,  that  the  succus- 
sion,  or  saltatory  agitation,  employed  by  Hip- 
pocrates, furnishes  a  physical  sign  of  pneumo- 
thorax with   liquid   effusion.     The  best  method 


148  PNEUMOTHORAX. 

of  obtaining  this  sign  is  by  the  patient  himself 
making  a  lateral  jerMmg,  or  a  half  rotatory  mo- 
tion with  his  trunk,  in  the  sitting  posture.  If 
he  be  too  weak  for  this,  the  succussion  may  be 
effected  by  another  person  applying  his  hands 
to  the  shoulders.  On  applying  the  ear  to  the 
chest,  in  such  a  manner  as  not  to  interfere  with 
the  motion  of  succussion,  the  fluctuation  of  the 
liquid  will  be  heard  as  in  a  cask  or  vessel  parti- 
ally filled,  when  it  is  shaken  ;  and  a  reference 
to  this  analogous  case  will  suggest  to  the  ope- 
rator the  most  effective  method  of  producing 
the  phenomenon.  The  roughness  of  this  me- 
thod of  examination  should  preclude  its  employ- 
ment in  all  cases  of  great  debility,  or  painful 
irritability  ;  for  although  I  believe  with  Laen- 
nec  that  it  is  much  less  fatiguing  than  would  at 
first  be  supposed,  yet  the  excitement  that  it 
produces  must,  in  these  cases,  be  necessarily  in- 
jurious. 

There  are  yet  other  signs  by  which  the 
auscultator  may  recognise  the  presence  of  air 
in  the  thorax.  They  are  of  singular  character, 
and  have  been  considered  of  different  explana- 
tion ;  but  I  apprehend  that  the  hitherto  too 
much  neglected  study  of  acoustics  will  furnish 
us  with  a  key  to  open  the  mystery.  Every  one 
knows  that  an  empty  room  yields  a  kind  of 
reverberation  or  prolonged  echo  to  any   soun$ 


EXPLANATION    OF    TINNITUS    METALLICUS.      149 

made  in  it.  Need  I  explain  that  this  echo  is 
the  sonorous  vibration  repeatedly  reflected 
from  the  walls  around.*  The  echo  is  in  such 
cases  chiefly  in  unison,  or  in  the  same  note 
with  the  original  sound.  But  substitute  for  the 
room  of  many  cubic  feet  capacity,  a  cavity  of 
only  a  few  cubic  inches,  the  sides  of  which  are 
still  good  and  uniform  reflectors  of  sound,  and 
then  a  soniferous  impulse,  communicated  to  the 
air  within  it,  will  be  so  rapidly  reflected  by  its 
parietes,  that  the  vibrations  will  be  increased  to 
a  double,  a  triple,  a  quadruple,  &c. ;  and  the 
reverberation,  instead  of  being,  as  in  the  former 
case,  in  unison  with  the  original  sound,  will  be 
in  its  octave,  its  12th,  its  15th,  its  22nd,  &c.f. 
Such  an  acute  note  rapidly   dying  away,  strong- 

*  The  more  perfectly  and  uniformly  reflective  the  walls,  floor  and 
ceiling  of  the  room  are,  the  more  complete  and  durable  will  be  the  re- 
verberation  ;  one  built  entirely  of  stone,  illustrates  this  in  perfection.  Tbe 
form  has  little  to  do  with  the  present  question,  except  that  themore  uniform 
the  surface,  the  less  is  the  original  sound  changed ;  and  a  hollow  sphere, 
therefore,  best  presents  this  condition.  The  complication  of  form  would 
modify  the  sound  ;  and  dissimilarly  reflecting  composition  would  neutralize 
or  destroy  it.  Hence  a  room  crowded  with  people,  with  various  fur- 
niture, yields  little  or  no  reverberation. 

|  In  short  in  its  octave,  and  in  any  of  its  harmonics  above.  This  is  ac- 
cording to  a  law  in  harmonics  well  known  to  scientific  musicians. 

These  acute  sounds  are  likewise  produced  in  the  reverberation  of  the 
large  room,  but  are  obscured  by  the  louder  note  of  unison  ;  just  so  a 
base  cord  in  vibration  may  be  said  to  contain  all  the  harmonics  above  its 
octave.  It  affords  by  itself  a  chord  of  real  harmony  ;  and  a  delicate  ear 
can  distinguish  five  or  six  of  its  contained  notes.  But.  the  subject,  .-\- 
ren  like,  seduces  me. 


150  PNEUMOTHORAX. 

ly  resembles  the  tinkling  sound  produced  by 
bodies  of  powerful  molecular  elasticity,  such  as 
glass,  metals,  &c.  The  elements  necessary  to 
produce  such  a  metalic  tinkling,  therefore,   are, 

1.  a  cavity  of  uniformly  reflecting   parietes  ;  and 

2.  the  communication  of  a  sound,  or  of  a 
soniferous  impulse  to  the  air  contained  within 
it*. 

Now  it   may  be   perceived  that  pneumotho- 
rax  may    combine     these    conditions  ;  let  us 

*  There  are  many  other  instances  of  the  production  of  this  metallic 
tinkling  in  the  body,  and  all  of  them  unite  these  conditions.  It  may  be 
heard  by  the  stethoscope  applied  to  the  stomach  of  a  person  swallowing 
water  by  teaspoonfuls.  It  may  often  be  heard  in  the  intestines,  distended 
with  gas  by  the  sudden  motion  of  liquid  in  them.  An  example  of  its  pro- 
duction, too  important  to  the  auscultator  to  pass  unnoticed,  occurs  in 
the  meatus  auditorius  externus,  on  covering  the  ear  with  the  palm,  and 
lightly  tapping  on  the  back  of  the  hand.  Now  this  sound  in  the  ear  is 
sometimes  excited  by  an  external  impulse  during  auscultation,  par- 
ticularly immediate,  and  might  be  readily  referred  to  the  chest  of 
the  patient.  Laennec  himself,  not  aware  of  the  facts  I  have  stated, 
has  fallen  into  this  error.  He  describes  in  his  second  vol.,  p.  445,  a 
cliquetis  metellique  occasionally  heard  in  the  precordial  region  of  persons 
affected  with  violent  nervous  palpitations  ;  and  considers  it  a  sign  of  the 
presence  of  some  bubbles  of  air  in  the  pericardium.  He  has  shown  me 
instances  of  this  symptom,  and  I  have  since  convinced  myself,  by  repeated 
observation,  that  it  is  produced  solely  in  the  meatus  by  the  impulse  com- 
municated to  the  air  within  it.  Other  instances  of  its  production,  as  on 
applying  the  hand  to  the  stethoscope  or  naked  ear  and  rubbing  together 
in  different  ways  the  fingers,  which  Laennec  refers  to  the  presence  of 
air  in  the  capsules  and  sheaths  of  the  tendons,  may  be  clearly  traced  to 
the  same  cause  by  any  one  who  will  take  the  trouble  to  vary  the  experi- 
ments. For  example,  lay  the  ear  flat  upon  the  table,  and  tap  the  table 
with  the  finger,  or  something  of  analogous  density,  and  the  stroke  will 
still  be  heard  accompanied  with  the  same  metallic  clink. 


SIGNS — TINNITUS    METALLICUS.  151 

study  what  forms  are  most  favourable  to  their 
union.  The  cavity  is  always  present  in  pneu- 
mothorax, but  it  is  best  calculated  to  produce 
the  tinkling  echo  when  its  parietes  are  tense 
and  regular,  as  when  the  lung  is  bound  down 
by  a  fibro-cartilaginous  membrane.  The  soni- 
ferous impulse  may  be  produced  within  the 
cavity,  or  may  be  communicated  to  it  from  with- 
out. The  only  cause  of  sound  within  the  cavity 
would  be  a  portion  of  liquid  contained  in  it, 
dropping  on  change  of  posture,  or  in  the 
motions  of  respiration,  from  the  upper  to  the 
lower  parts.  Such  a  case  of  metallic  tinkling 
is  rare,  but  Laennec  records  an  instance,  and  I 
have  myself  met  with  one.  The  sound  is  in 
this  instance,  as  Laennec  describes,  like  that  of 
a  drop  falling  into  a  decanter,  a  fourth  full  of 
water,  followed  by  a  prolonged  ringing.  The 
symptom  in  this  case  of  course  indicates  the 
presence  of  liquid  as  well  as  of  air  in  the 
pleura. 

Sounds,  external  to  the  cavity,  may  cause  the 
tinkling  echo  within  it  ;  and  they  may  be 
communicated  in  several  ways.  Thus  a  fistu- 
lous communication  with  the  bronchi  may  trans- 
mit a  sonific  impulse  to  the  caVity  on  the 
occasion  of  speaking  or  coughing,  and  this  is 
by  far  the  most  common  case  of  tinnitus 
metallicus.     It  is  here  most  perfectly  produced 


152  PNEUMOTHORAX. 

when  the  fistulous  communication  is  short,  but 
narrow,  and  the  bronchus  is  of  considerable 
size.  The  sound  is  then  heard  immediately 
after  the  cough  or  utterance,  like  that  yielded 
by  a  wine  glass  when  struck  by  a  pin,  and  is  of 
longer  or  shorter  duration.  Sometimes,  but  more 
rarely,  the  same  tinkling  sound  accompanies  re- 
spiration. If  the  fistulous  communication  be  large 
or  if  there  be  several,  the  tinkling  is  changed 
into  a  hollow  buzzing  sound,  like  that  pro- 
duced by  blowing  into  an  empty  bottle  ;  where- 
fore Laennec  calls  it  amphoric  resonance.  This 
is  most  distinctly  heard  during  respiration,  but 
likewise  accompanies  the  cough  and  the  voice. 
Amphoric  resonance  is  obviously  caused  by  the 
passage  of  air  in  and  out  of  the  pleural  cavity. 
This  passage  of  air  deranges  the  reverberations 
that  produce  the  tinkling  echo  within  the 
cavity ;  hence  amphoric  resonance  either  im- 
pairs, or  completely  destroys  the  tennitus  metal- 
licus.  Let  the  observer  bear  in  mind  these  cir- 
cumstances, and  he  will  then  perceive  how 
metallic  tinkling  may  be  succeeded  by  amphoric 
resonance,  on  an  enlargement  of  the  fistulous 
communication  with  the  bronchi ;  and  how  the 
converse  may  result  from  its  contraction,  and 
that  both  will  cease  on  its  occlusion.  To  some 
degree  the  same  effects  may  proceed  in  certain 
cases    from   different    degrees    of  force  in  the 


CAUSES    OF    THE    METALLIC    TIXKLIXG.  153 

respiratory  movements,  which  may  of  them- 
selves open  and  shut  the  fistulous  aperture.  In 
all  cases  on  record,  this  form  of  pneumothorax 
has  been  accompanied  with  more  or  less  liquid 
effusion,  and  probably  this  is  a  necessary  attend- 
ant of  the  pleurisy  excited  by  the  access  of  air 
or  extraneous  matter  through  a  fistulous  com- 
munication with  the  bronchi.  That  may  there- 
fore be  anticipated,  which  I  have  had  frequently 
occasion  to  observe  in  practice,  that  this  liquid, 
by  occasionally  covering  more  or  less  complete- 
ly the  fistulous  aperture,  may  also  modify,  di- 
minish, or  destroy  either  of  the  symptoms  which 
I  have  been  describing.  Hence  change  of 
posture,  by  altering  the  situation  of  the  liquid, 
may  assist  the  auscultator  to  the  discovery  of 
the  symptom ;  and  in  some  cases  might  even 
lead  him  to  calculate  the  situation  of  the  fistu- 
lous aperture. 

Laennec  considered  metallic  tinkling  a  pa- 
thognomonic sign  of  pneumothorax  with  liquid 
effusion  and  fistulous  communication  with  the 
bronchi.  The  accuracy  of  this  opinion  I  am 
led  by  theory  and  experience,  to  call  in  ques- 
tion. From  the  theory  that  I  have  given,  it 
may  be  judged  that  although  such  a  lesion  may 
be  the  most  frequent  cause  of  this  symptom, 
it  needs  not  such  a  complicated  state  to  pro- 
duce it.  The  cavity  being  present,  as  we  have 
20 


154  PNEUMOTHORAX — SIGNS. 

said,  in  pneumothorax,  a  cause  of  the  tinkling 
echo  in  it  may  be  found  in  the  transmission  of 
a  sound  or  sonific  impulse  through  solid  pari- 
etes.  For  example,  the  voice  or  cough  may 
communicate  such  impulse  whenever,  by  an  in- 
duration or  condensation  of  the  pulmonary  tis- 
sue, it  is  rendered  capable  of  conducting  to  the 
cavity  the  sound  from  any  large  bronchial  tubes. 
Such  a  condensation,  we  have  seen  may  be  pro- 
duced by  inflammation,  and  by  the  pressure  of  a 
liquid  effusion,  and  might,  doubtless,  in  some 
cases  result  from  the  pressure  of  the  air  of  the 
pneumothorax  itself.  Add  to  these  the  case  of 
pneumothorax,  combined  with  such  tuberculous 
excavation  of  the  lung  that  pectoriloquous  re- 
sonance is  transmitted  from  it  to  the  pleural 
cavity,  but  without  fistulous  communication  : — 
So  far  in  theory. 

Now  in  the  way  of  fact,  Laennec  himself  fur- 
nishes two  examples,  which  analytically  prove 
the  point  at  which  we  have  arrived  by  theory. 
In  one,  the  tinkling  was  produced  in  pneumo- 
thorax, where  there  was  no  communication 
with  the  bronchi  or  external  air,  by  the  drop- 
ping of  a  liquid  in  the  cavity*.  Another  case 
presented  the  tinkling  echo  after  the  voice, 
although  there  was  no  communication  with  the 
bronchi,  but  only  with  the  external  air  through 

*  The  case  before  alluded  to,  Tome  II,  p.  348,  of  Laennec. 


METALLIC    TINKLING.  155 

a  puncture  in  the  thoracic  parietes  (Tome  I, 
p.  113.)  These  cases  remove  two  of  the  con- 
ditions specified  by  Laennec,  as  necessary  to 
the  production  of  metallic  tinkling ;  namely, 
communication  with  the  external  air ;  and 
transmission  of  the  voice  through  a  fistulous 
opening  in  the  bronchi. 

The  following  case,  which  fell  under  my  ob- 
servation in  the  ward  of  M.  Lerminier,  at  La 
Charite,  shews  that  the  presence  of  liquid  effu- 
sion is  likewise  dispensible.  A  boy,  fifteen 
years  of  age,  had  been  for  some  weeks  affected 
with  pectoral  disease,  with  cough,  shortness  of 
breathing,  scanty  expectoration,  &c,  but  these 
had  somewhat  abated,  until  a  few  days  before, 
when  they  had  become  considerably  aggravated. 
When  I  first  saw  him,  he  had  besides,  much 
fever,  quick  pulse,  pain  of  side  and  other  symp- 
toms of  an  acute  attack.  On  percussion  the 
left  side  sounded  well  every  where,  but  in  the 
inferior  or  lateral  and  posterior  region,  where  it 
was  rather  duller  than  usual.  The  right  side 
was  very  sonorous  on  percussion  anteriorly  and 
laterally,  below  the  fourth  rib  ;  less  so  above,  and 
posteriorly.  On  auscultation,  the  respiration 
of  the  left  side  was  distinct  superiorly  and  an- 
teriorly, but  mixed  with  crepitant  rhonchus 
laterally  and  posteriorly,  particularly  in  the  in- 
ferior   parts.      No   bronchophony  or  bronchial 


156  PNEUMOTHORAX. 

respiration.  On  the  right  side  the  respiration 
was  puerile  below  the  clavicles  and  in  the  axilla, 
and  above  the  spine  of  the  scapula;  became  less 
distinct  somewhat  below,  and  was  quite  inau- 
dible below  the  fourth  rib,  the  part  most  sono- 
rous on  percussion.  In  this  also,  after  cough 
and  utterance,  a  distinct  metallic  tinkling  was 
heard,  which  appeared  not  to  be  affected  by 
change  of  posture.  The  next  day  the  same 
symptoms  were  present,  but  the  crepitant  rhon- 
chus  had  extended  upward  in  the  left  lung ; 
and  the  patient  seemed  worse.  Tinnitus  as 
before.  Died  in  the  course  of  the  day.  On 
dissection,  about  eighteen  hours  after  death, 
about  the  inferior  and  anterior  half  of  the  right 
side  of  the  chest  was  found  filed  with  air,  some 
of  which  escaped  with  a  hissing  noise  on  first 
incision  ;  the  lung  was  bound  down  to  the  whole 
of  the  posterior,  and  the  upper  portions  of  the 
lateral  and  anterior  parietes  of  the  thorax,  by 
a  pretty  firm  fibro-cartilaginous  membrane, 
which  also  thickened  the  costal  pleura  of  the 
cavity.  There  ivas  not  a  drop  of  liquid  in  the 
cavity^  and  there  was  no  communication  with  the 
bronchi.  In  the  inferior  lobes  of  the  compressed 
lung  were  found  three  hydatids  contained  in, 
but  not  connected  with,  a  cavity  lined  with,  a 
fibrous  membrane.  The  tissue  of  the  lung  was 
flaccid,  and   compressed  in   their  vicinity,  and 


METALLIC    TINKLING.  157 

bounding  the  cavity  containing  air,  but  above 
it  was  healthy  and  crepitant.  The  lower  lobes 
of  the  left  lung  were  found  in  a  hepatized  state, 
which  passed  superiorly  into  simple  inflamma- 
tory engorgement  ;  and  still  higher  up  the  tis- 
sue was  healthy.  There  were  no  tubercles  in 
either  lung.  The  rationale  of  the  symptoms  is 
in  this  case  obvious.  The  tinkling  echo  was 
produced  in  the  cavity  by  the  voice,  transmitted 
to  it  by  the  pulmonary  tissue  condensed  by  the 
hydatids,  and  perhaps  also  by  a  former  liquid 
effusion  in  the  pleura.  This  effusion  had  been 
absorbed,  and  the  lung  being  bound  down  by  a 
factitious  membrane,  a  pneumothorax  of  neces- 
sity was  left.  Such  a  case  of  tinnitus  metalli- 
cus  must  be  very  rare,  as  neither  Laennec  nor 
Andral  have  met  with  it :  and  I  believe  that 
although  not  in  all,  yet  in  by  far  the  majority  of 
cases,  the  organic  causes  of  metallic  tinkling 
are  such  as  Laennec  has  defined  them.  The 
liquid  effusion  I  cannot  consider  as  one  of  the 
causes  combining  to  produce  it,  but  merely  a 
necessary  accompaniment  of  its  cause,  fistulous 
communication  between  the  pleura  and  bronchi, 
T  have  been  longer  on  this  article  than  its 
importance  may  seem  to  require,  but  the  obscu- 
rity of  the  subject  demanded  it ;  and  if  I  have 
shewn  that  the  stethoscopic  signs  are  less  cer- 
tain than  they  have  been  represented  to  be,  this 


158  PHTHISIS    PULMONALIS. 

may  prevent  future  error,  and  improve  our 
knowledge  by  guiding  us  to  others  more  defi- 
nitive. 


CHAP.  IV. 

PHTHISIS    PULMONALIS. 

Section  I. — Pathology. 

The  disease  termed  phthisis  pulmonalis,  is 
produced  by  the  formation  of  a  particular  matter 
called  tubercle,  in  the  tissue  of  the  lungs.  It 
would  perhaps  be  more  consistent  with  the  order 
of  the  work,  if  I  had  placed  this  disease  among 
those  affecting  particularly  the  pulmonary  tex- 
ture ;  but  I  have  been  induced  to  prefer  allotting 
to  it  this  separate  chapter  because  the  previous 
examination  of  other  simple  diseases  will  better 
enable  us  to  understand  the  pathology  of  this 
more  complicated  one. 

I  shall  first  trace  the  progress  of  the  changes 
which  morbid  anatomy  has  shewn  tubercles  to 
undergo  in  the  progress  of  the  disease,  and 
afterwards  inquire  into  their  nature  and  origin. 

The  lungs  of  those  who  die  phthisical,  pre- 
sent some,  or  all  of  the  following  changes  : — 


GRANULATIONS.  159 

1.  Small,  roundish,  semi-transparent  bodies,  of 
greyish  or  ash-coloured  hue,  of  different  shades, 
of  a  size  varying  from  that  of  a  millet  seed  to 
that  of  a  hempseed,  and  of  hardness  nearly 
equal  to  that  of  cartilage.  These  little  bodies 
are  dispersed  about  the  substance  of  the  lung 
in  variable  numbers,  here  isolated,  and  in  a 
tissue  otherwise  healthy  ;  there  agglomerated 
together  in  clusters,  and  surrounded  by  texture 
more  or  less  diseased.  Some  are  found,  on 
close  examination,  and  on  incision,  to  differ 
from  others,  in  having  within  them,  generally, 
but  not  always,  about  their  centre,  an  opake 
yellowish  white  spot,  which,  traced  in  different 
ones,  may  be  observed  to  be  small  in  some, 
larger  in  others,  and  in  some  to  constitute  the 
principal  part  of  the   little  miliary  body. 

2.  A  diffused  induration  of  the  pulmonary 
tissue,  in  colour  and  consistence  resembling  the 
preceding,  but  of  greater  extent  than  they,  and 
confined  to  no  particular  size  or  form.  The 
texture  of  the  lung  can  no  longer  be  detected 
in  the  part  thus  affected,  and,  when  cut  into,  it 
presents  a  mist,  homogeneous  shining  surface, 
and  is  totally  impermeable  to  air.  Sometimes 
the  duration  is  inconsiderable,  although  the 
other  characters  remain  ;  and  in  rarer  cases  the 
change  seems  to  be  produced  by  the  infiltration 
of  a  matter  nearly  gelatinous,    slightly  sangui- 


160  PHTHISIS    PULMONALIS. 

nolent,  which  more  or  less  obliterates  the  pul- 
monary texture.  This  might  be  considered  a 
distinct  alteration  from  the  others,  were  it  not 
that  their  coincidence  and  mutual  gradations 
seem  to  identify  them*.  The  tissue  thus  affected 
becomes,  like  the  miliary  granulations,  invaded 
by  the  yellowish  white  spots  ;  only  these  spots 
here  appear  irregular  as  to  form  and  num- 
ber, and  extend,  and  gradually  convert  the  whole 
into — 

3.  Opake  masses,  of  a  yellowish  white  colour, 
of  various  size,  generally  of  a  roundish  form, 
and  of  consistence  at  first  considerable,  and 
nearly  equal  to  that  of  the  matter  in  which 
they  were  produced  ;  but,  in  the  course  of  time, 
they  gradually  become,  in  consistence  and  co- 
lour, like  soft  cheese,  and  at  length  attain 
the  liquidity  of  puss  :  this  change  always  begin- 
ning towards  the  centre.  The  miliary  bodies 
become  likewise  converted  into  little  yellow  gra- 
nular tubercles  when  isolated ;  but  when  in  a 
cluster,  frequently  run  together  into  one  tuber- 
cular mass  of  considerable  size.  The  yellow 
tubercular  masses  formed  in  the  diffused  indu- 
ration may,  of  course,  be  of  form  and  size  as 
varied  as  those  of  the  matrix  in  which  they  are 

*  This  gelatinous  effusion,  according  to  Laennec,  is  generally  ob- 
served accompanying  the  miliary  granulations  before  mentioned,  particu- 
larly secondary  ones,  produced  after  others  have  suffered  the  changes  to 
be  described  immediately. 


PATHOLOGY — EXCAVATIONS.        161 

developed.  But  the  yellow  tubercle  seems 
likewise  sometimes  to  increase  of  itself,  to  ex- 
tend beyond  the  limits  of  the  previous  indura- 
tion, and  to  encroach  on  the  surrounding  tissue, 
Tn  some  few  instances  this  progress  is  limited 
by  the  formation  of  a  fibrous  cyst.  The  yellow 
tubercular  matter  is  apparently  produced  in 
some  cases,  without  the  previous  induration, 
whether  miliary  or  diffused  ;  and  a  yellow  tu- 
bercular infiltration  of  this  kind  is  not  unfre- 
quently  found  in  the  lungs  of  children.  After 
the  softening  of  the  tubercular  matter,  it  is 
evacuated  by  a  fistulous  communication,  ge- 
nerally into  the  bronchi,  and  rarely  into  the 
pleural  sac, 

4.  After  the  softened  tubercular  matter  is 
evacuated,  an  ulcerous  cavity  is  left,  which  pre- 
sents to  the  anatomical  observer  a  great  variety 
of  form.  The  walls  of  the  cavity  are  sometimes 
simply  the  pulmonary  tissue,  more  or  less 
red  with  inflammation.  The  result  of  this  in- 
flammation (excited  probably  by  the  irritation 
of  the  tubercular  matter,)  is,  during  life,  on 
the  one  hand  the  condensation  of  the  pulmo- 
nary texture  surrounding  the  cavity  ;  and,  on 
the  other,  the  secretion  of  liquids  more  or 
less  purulent,  and  of  a  coagulable  lymph,  by 
which  a  kind  of  lining  is  formed  within  the  ca- 
vity. The  effect  of  this  latter  process  is  shown 
21 


162  PHTHISIS    PULMONALIS. 

in  its  various  stages  of  advancement  in  the  ca- 
vities of  different  ages  that  are  met  with  on  the 
examination  of  phthisical  lungs.  The  coagu- 
lable  lymph  becomes,  in  time,  converted  into  a 
fibro-cartilaginous  membrane,  the  thickness  and 
firmness  of  which  are  generally  in  proportion  to 
its  age. 

The  cavities  are    very     various   in  size  and 
form.     Some  wrould  not   contain   more   than  a 
pea,  while,  occasionally,  a  cavity  is  found   occu- 
pying a  whole  lobe.     Cavities  of  large  size  are 
most  commonly  formed  by  the  reunion   of  many 
smaller  ones,    produced  by  the   evacuation   of 
their  softened     tubercular    contents.     The    ul- 
cerative   process,    as  it  is   necessary  to   open  a 
communication  between  cavity  and  cavity,  and 
between  these  and  the  bronchi,  so  also  often 
extends  the  limits    of  a   cavity  by    encroaching 
on   the  healthy  tissue.     In    this   way  a  lobe  is 
sometimes  reduced  to  a  mere     sac,    composed  of 
the  pleura,  and  a   thin  layer  of  condensed   pul- 
monary tissue.     In  other  instances    the  ulcera- 
tive process  has  been  less  active,  and  the  cavity 
may  then  be  sinuous,  multilocular,  or  composed 
of    several  small   cavities  communicating    with 
each  other.     Occasionally,   bands  of  condensed 
pulmonary  tissue,  crossing  a  cavity,  are   all  that 
remain  of  the   divisions  of  former  small    ones. 
Cavities  recently  formed,  or  which  have  only 


PATHOLOGY.  163 

recently  communicated  with  the  bronchi,  usu- 
ally contain,  besides  some  remains  of  the  tuber- 
cular matter  in  the  form  of  a  curdy  liquid,  pus, 
and  a  greyish  or  brownish  grumous  liquid,  se- 
creted by  the  inflamed  parietes.  Sometimes  a 
little  blood,  is  found  mixed  with  these,  but  this 
is  seldom  to  a  great  extent,  as  the  vessels  which 
terminate  in  the  cavity  are  almost  constantly 
closed  by  coagula,  and  the  adhesive  inflamma- 
tion. The  quantity  of  liquid  secreted  by  tu- 
bercular cavities  is  diminished  by  the  formation 
of  a  fibrocartilaginous  lining,  and  when  this  is 
complete,  the  secretion  is  nothing  more  than  a 
scanty  serous,  or  sero-mucous  liquid.  Thus  far 
of  the  anatomical  history  of  phthisis  pulmonalis  ; 
more  particulars  will  be  learnt  from  its  physical 
signs. 

It  appears,  then,  that  the  principal  changes 
of  the  tissue  of  the  lung  in  phthisis  pulmonalis 
are  of  two  kinds  ;  1 .  an  induration  of  a  grey,  or 
greyish  brown  colour ;  2.  the  production,  ge- 
nerally in  this  induration,  sometimes  elsewhere, 
of  a  yellowish  white  matter,  at  first  rather  hard, 
but  becoming  gradually  softer,  until  it  attains  the 
liquidity  of  pus.  Now,  let  us  endeavour  to  dis- 
cover what  is  the  essential  nature  of  each  of 
these  changes,  what  it  is  that  causes  them,  and 
in  what  relation  they  stand  to  each  other. 

Now,   in  the  grey  induration   of  the  pulmo- 


164  PHTHISIS    PULMONALIS. 

nary  tissue,  whether  granular  or  diffused,  two 
things  are  remarkable  ;  first,  that  there  is  an 
increase  of  substance,  for  the  spongy  texture  of 
the  lung  is  obliterated  and  solidified  ;  secondly, 
that  its  substance  is  harder  than  the  healthy 
tissue*  ;  the  first  denoting  the  deposition  of  a 
greater  number  than  usual  of  molecules  by  the 
nutritive  secretion  ;  and  the  second  proceeding 
partly  from  the  same  cause,  and,  perhaps,  partly 
from  these  molecules  being  unusually  solid. 
Now  the  local  increase  in  the  nutritive  secre- 
tion must  have  been  preceded  by  locally  in- 
creased vascular  action  ;  and  from  the  degree 
by  which  the  increased  secretion  exceeded  that 
of  simple  hypertrophy  of  the  existing  parts,  and 
amounted  to  an  overflow  and  effusion  in  their 
interstices  ;  it  may  be  judged  that  this  patho- 
logical increase  was  not  less  than  inflammation. 
Inflammation  we  know  to  cause  an  external 
overflow  of  the  nutritive  secretion  ;  and  I  have 
before  f  endeavoured  to  show  why  the  acute 
form  should  generally  produce  a  soft  tumefac- 
tion, and  the  chronic  an  indurated  increase  of 
substance  ;  facts  sufficiently  established  by 
Andral  and  others.     How,  then,    can  we  view 

*  M.  Andral  has  remarked  that  miliary  granulations  do  not  always  pre- 
sent this  indurated  form,  but  that  a  careful  examination  may  often  detec 
small  bodies  of  the  same  shape  and  size,  but  of  soft  consistence,  and  of  at 
red  colour. 

t  See  Section  on  Pleurisy,  p.  115. 


NATURE    OF    TUBERCLE.  165 

the  induration  of  the  lung  which  precedes  the 
formation  of  tubercular  matter  in  any  other 
light  than  in  that  of  an  effect  of  chronically  in- 
creased vascular  action  ;  in  short,  of  chronic 
inflammation  ?  Let  us,  by  following  it  in  its 
further  progress,  see  whether  its  ulterior  changes 
destroy  or  increase  the  analogy. 

We  have  found  that,  after  a  time  more  or 
less  protracted,  the  indurated  grey  semi-trans- 
parent, but  still  organized  mass,  presents  whitish 
points  or  spots,  which  increase  in  size,  and  at 
length  convert  the  whole  mass  into  a  substance 
of  a  yellowish  white  colour;  this  generally  re- 
tains at  first  the  former  consistence,  but 
gradually  losing  it,  becomes  that  soft  and 
grumous  substance,  known  under  the  name  of 
matured  tubercles.  Here  there  is  no  longer 
organization,  no  longer  distinction  of  parts  ; 
where  these  were,  there  is  now  but  one  con- 
fused amorphous  magma.  Now  who  can  fail 
to  see  in  this  change  a  close  resemblance  to  the 
familiar  process  of  suppuration?  familiar,  but 
not  less  obscure  than  this.  If  the  resemblance 
is  so  perfect  in  the  generalities,  should  some 
slight  variations  in  particulars,  still  explicable 
from  a  difference  of  cause,  by  widely  separat- 
ing the  two  phenomena,  be  made  a  pretext  to 
multiply  the  objects  that  the  mind  should 
grasp?     If  the  fact  may  be  referred  to   a  simple 


166  PHTHISIS    PULMONALIS. 

and  established  law,  shall  we  still  leave  it  in  the 
already  burthened  and  unwieldy  list  of  anoma- 
lous exceptions  ?  No  one  is  more  than  myself 
averse  from  hasty  and  excessive  generalization  : 
but  still  more  am  I  an  enemy  to  multiplying 
rules,  when  the  advance  of  science  is  daily  re- 
ducing knowledge  into  simpler  forms.  For 
this  reason  I  would,  were  the  arguments  equal, 
incline  to  consider  tubercles  the  result  of  a  kind 
of  inflammation,  rather  than  with  Laennec, 
form,  on  their  instance,  a  new  set  of  laws  apart, 
to  be  applied  to  such  bodies,  under  the  un- 
meaning term  of  accidental  tissues*. 

But  I  think  that  none  of  the  objections 
usually  opposed  to  the  opinion  that  tubercles 
are  produced  by  inflammation  will  apply  to  this 
view.     From  our  inquiry  we  have   been   led  to 

*  Much  as  Laennec  has  done  in  elucidating  the  history  of  phthisis 
pulmonalis,  his  opinions  on  tubercles  and  other  diseased  productions  have 
always  appeared  to  me  artificial  and  unsatisfactory.  Tubercles,  accord- 
ing to  this  author  an  accidental  tissue,  are  produced,  or,  according  to 
some  of  his  expressions,  spring  up,  in  a  healthy  tissue,  without  any  aid 
of  the  vessels  of  the  part ;  are  changed  from  a  greyish  semi-transparent 
to  an  opake  yellowish  white,  and  pass  from  a  state  of  cartilaginous  hard- 
ness through  intermediate  gradations,  into  that  of  imperfect  liquidity; 
and  all  this  by  mechanism  perfectly  unknown,  and  in  a  manner  entirely 
unexplained.  It  is  too,  in  my  opinion,  without  sufficient  reason,  that  he 
identified  the  granulations  of  Bayle  with  the  yellow  tubercle,  bodies  quite 
different  in  their  physical  character,  only  because  the  one  is  generally  in 
time  converted  into  the  other. — As  well  might  cartilage  be  called  bone, 
or,  (if  the  example  does  not  involve  a  petitio  principii)  inflamed  cellular 
texture,  a  stage  of  p  us. 


NATURE    OF    TUBERCLE.  167 

consider  the  induration  which  precedes  tubercle 
as  the  result  of  a  peculiar  form  of  inflammation, 
or  increased  vascular  action,  and  the  vellow 
tubercular  matter  which  succeeds,  a  further 
effect  of  the  same  inflammation,  analogous  to 
suppuration.  It  has  been  objected  by  Laennec 
and  others,  who  have  denied  the  inflammatory 
origin  of  tubercles,  that  phthisis  is  by  no  means 
a  common  sequel  of  pneumonia  ;  and  I  believe 
that  the  case  is  not  sufficiently  common  to 
support  the  opinion  that  the  latter  is  often  the 
immediate  cause  of  the  former ;  but  the  suc- 
cession does  not  appear  too  rare  to  exclude  the 
supposition  that  acute  inflammation  of  the 
lungs,  by  passing  into  a  chronic  form,  may 
terminate  in  phthisis  pulmonalis ;  just  as  we 
know  chronic  peritonitis,  pleuritis,  &c,  some- 
times date  their  origin  in  an     acuteattack.* 

This  is  not,  however,  the  principal  question, 
although  one  of  itself  of  great  practical  impor- 
tance :    the    main  point   to    be   disputed,    and 

*  The  researches  of  my  respected  friend,  Professor  Alison,  go  far  t  o 
prove  that  even  acute  inflammation  may  determine  the  development  of 
tubercular  matter.  I  have  with  him  dissected  the  lungs  of  a  child,  in 
which  matter,  bearing  all  the  physical  character  of  tubercle,  was  found  in 
parts  in  the  acknowledged  state  of  inflammation,  whilst  the  healthy 
portions  were  free.  Andral  has  recorded  similar  cases  ;  and,  as  will 
appear  from  the  opinions  that  I  afterwards  expose,  I  consider  it  as 
highly  probable  that  many  cases  of  what  is  called,  gaUoppmg  consumption 
are  instances  of  the  development  of  tubercular  matter,  by  acute  inflamma- 
tion in  subjects  of  a   strong  phthisical   diat;. 


168  PHTHISIS    PULMONALIS. 

which  Laennec  seems  to  have  evaded,  is  whether 
the  grey  induration  of  the  lung,  which  pre- 
cedes the  formation  of  tubercular  matter,  is  not 
itself  the  result  of  a  peculiar  inflammatory 
state,  standing  in  the  same  relation  to  chronic, 
as  hepatization  does  to  acute  pneumonia.  We 
have  already,  on  a  physiological  discussion  of 
the  subject,  been  led  to  answer  this  question  in 
the  affirmative.  Laennec,  following  the  opposite 
opinion,  has  met  with  so  few  cases  which  he 
could  consider  instances  of  chronic  peripneu- 
mony,  that  his  view  leaves  it  an  extraordinary 
anomaly,  that  the  lungs  should  be  so  rarely 
affected  with  chronic  inflammation*.  So  far 
it  seems  reasonable  and  consistent  with  ana- 
logy* to  consider  the  lesion  in  question  as 
chronic  inflammation.  Pathological  anatomy, 
which  was  negative  in  the  hands  of  Laennec, 
favoured  this  view  in  the  researches  of  Andral, 
by  shewing  the  gradations  which  might  be 
traced  between  inflammation  and  grey  indura- 

*  The  only  kind  of  explanation  that  Laennec  offers  is  far  from  being 
satisfactory.  Speaking  of  chronic  inflammation,  he  says,  "  il  semble  peu 
probable  qu'  un  organe  aussi  vasculaire,  aussi  mobile  aussi  essentielle- 
ment  vivant  que  le  poumon,  puisse  conserver  longtemps  1'  inflammation 
a  ce  degre  de  lenteur  et  d'inactivite  qui  existe  souvent  dans  les  affections 
semblables  d'organes  moins  necessaires  a  la  tvie."  (T.  1.  p.  475.)  This 
objection,  which  if  it  had.  any  force,  ought  to  exclude  its  occurrence  at 
all,  is  just  as  applicable  on  the  score  of  vascularity  to  chronic  inflamma- 
tion in  many  glandular  organs,  and  on  the  score  of  vitality  to  the  destruc- 
tion of  the  function  of  parts  of  the  lung  itself,  by  what  Laennec  calls 
accidental  tissues. 


NATURE    OF    MILIARY  GRANULATIONS.      169 

tion,  and  the  apparent  transition  of  the  one 
into  the  other.  I  have  myself  seen  cases  in 
which  some  portions  of  the  lung  were  of  a 
dark  reddish  colour,  dense,  but  not  indurated  ; 
other  portions  were  lighter  in  colour,  of  a 
browner  hue,  and  harder  in  consistence ;  other 
parts  again,  had  little  of  the  brown  tinge,  but 
were  more  grey  from  the  mixture  of  black 
pulmonary  matter,  and  in  consistence  likewise, 
closely  resemble  the  grey  induration  before 
described  ;  while  in  the  vicinity,  this  lesion 
itself  also  occurred  in  T?n  unequivocal  form. 

What  I  have  here  said  of  induration  in  ge- 
neral, will  apply  equally  to  the  circumscribed 
form,  or  miliary  granulations,  and  to  the  dif- 
fused induration  ;  for  they  appear  to  differ  only 
in  respect  to  size.  The  constant  form  and 
shape  that  these  miliary  granulations  present, 
become  another  matter  of  inquiry  ;  and  it  seems 
probable  that  they  are  some  elementary  part  of 
the  lung  in  the  state  of  chronic  inflammation. 
Broussais  conceives  them  to  be  the  lymphatic 
glands ;  whilst  Andral  considers  them  as  the 
individual  vesicles,  or  single  terminations  of  the 
bronchi.  The  latter  opinion  seems  the  most 
probable,  and  is  most  in  accordance  with  my 
own  examinations  ;  but  it  requires  yet  further 
confirmation  to  be  established. 

We  are  then  led  to  consider,  with  Andral,  yel- 

22 


170  PULMONARY    PHTHISIS. 

low  tubercular  matter  as  nothing  more  than  a 
modification  of  pus,  and  a  tubercle  as  a  kind  of 
abcess.  In  the  formation  of  the  yellow  tu- 
bercle, the  indurated  tissue  is  removed  by  ab- 
sorption, and  tubercular  matter  deposited  in  its 
place  *.  Although  the  grey  induration  is  not 
known  to  have  any  other  termination  than 
this  in  tubercular  abcess,  and  may,  therefore, 
be  considered  a  stage  of  the  disease,  yet  the 
more  peculiar  characters  of  phthisis  pulmo- 
nalis  depend  on  the  formation  or  secretion  of 
tubercular  matter.  Now,  this  tubercular  matter, 
of  albuminous  composition,  must  be  considered 
a  modification  of  the  nutritive  secretion,  still 
more  destitute  of  vitality!    than  pus,   and  quite 

*  Since  this  was  written,  I  have  read,  with  much  interest,  the  Thesis  of 
my  friend,  M.  Lombard,  of  Geneva;  "  Sur  les  Tubercules ;  Paris,  1827** 
He  divides  tubercles  into  simple  and  compound  ;  and  ingeniously  ex- 
plains the  softening  of  the  substance  of  the  latter  by  ascribing  it  to  the 
operation  of  the  living  portions  of  tissue  that  (as  he  has  found)  still  per- 
vade it.  With  Andral  and  myself  he  renounces  the  idea  of  tubercles 
being  an  accidental  tissue,  or  identical  with  the  grey  induration  ;  but 
considers  them  a  peculiar  matter  secreted  by  cellular  texture,  in  a  state 
of  active  or  passive  sanguineous  congestion.  The  view  which  he  gives 
of  accidental  productions  seems  to  me  the  most  simple  and  philosophical 
that  has  yet  been  offered  ;  and  the  whole  work,  as  well  as  my  acquaint- 
ance with  the  abilities  of  the  author,  give  me  reason  to  congratulate  the 
profession  that  he  is  still  engaged  on  this  important  subject,  and  will  soon 
lay  before  the  world  the  result  of  his  extended  labours. 

f  I   use  this  word  rather  to   avoid  circumlocution,   than   as  implying 
such  a  life  in  animal   fluids  as  Hunter  ascribed  to  them.     Capability  of 
life  would,  perhaps,   more   nearly  express  my  meaning ;  and  this  seems 
to  be  generally  proportionate,  in  the  products  of  inflammation,   to  the 
energy  of  the  orgasm,  the  overflow  of   vitality  that  generates  them. 


PATHOLOGICAL    CAUSES.  171 

incapable  of  organization.  Although  it  may, 
therefore,  be  generally  considered  the  result 
of  a  lower  degree  of  vascular  action  than  that 
which  produces  pus,  yet  it  appears  to  be  some- 
times secreted  by  vessels  inflamed  in  different 
degrees,  and  even  by  those  not  inflamed  at  all. 
It  is  this  disposition  in  vessels,  in  different  states 
of  activity,  to  tubercular  secretion,  that  consti- 
tutes, what  is  called  tuberculous  diathesis ;  and 
where  this  prevails,  the  pulmonary  and  other 
tissues,  apparently  unaffected  with  inflamma- 
tion, are  sometimes  found  infiltrated  with  tu- 
bercular matter.  Whatever  be  the  cause  which 
determines  the  secretion  in  these  cases*,  the 
formation  of  pus  appears  also  to  be  sometimes  in 
the  same  predicament ;  for  I  have  known  cases, 
and  Andral  records  some,  in  which  the  presence 
of  pus,  whether  in   abscess,  or  secreted  by  a 

*  M.  Andral  hints  that  the  disease  may  here  be  humoral,  and  depend  on 
the  formation  of  tubercular  matter  in  the  blood,  and  the  idea  appears  plau- 
sible. I  am  myself  disposed  to  consider  tubercular  matter,  pus,  and  coagu- 
lable  lymph,  only  as  varieties  of  the  same  albuminous  matter  that  exists  in 
the  blood,  and  differing  from  each  other  rather  in  mechanical  condition, 
and  consequent  capability  of  organization,  than  in  chemical  composition. 
In  this  view,  if  the  blood  is  perfect,  the  difference  of  the  secretion  will  de- 
pend entirely  on  the  degree  of  increase  in  the  vascular  action,  but  if  the 
blood  itself  be  imperfect  or  diseased,  then  whatever  be  the  degree  of  in- 
flammation, perhaps  the  source  may  be  incapable  of  furnishing  more  than 
one  or  other  form  of  secretion,  and  this  inability  may  even  extend  to  the 
process  of  reparatory  nutrition.  I  shall,  however,  forbear  to  explain  fur- 
ther these  opinions,  for  they  must  appear  too  hypothetical,  with  any  sub- 
•tantiatory  confirmation  that  I  could  give  them  in  toil  place. 


172  PULMONARY   PHTHISIS. 

membrane,  had  been  neither  preceded   nor  ac- 
companied by  other  marks  of  inflammation, 

I  think,  then,  that  it  is  of  sufficient  impor- 
tance to  distinguish  three  ways  in  which  the 
lungs  may  become  infested  with  tubercular 
matter. 

1.  By  the  tubercular  suppuration  of  the  in- 
durations, whether  granular  or  diffused,  which 
we  have  been  induced  to  consider  chronic  in- 
flammations of  the  pulmonary  tissue  ;  this 
being  the  natural  termination  of  such  inflamma- 
tion. 

2.  By  tubercular  suppurations  of  other  inflam- 
mations of  the  pulmonary  tissue  ;  this  effect  be- 
ing determined  by  the  prevalence  of  the  tuber- 
cular diathesis. 

3,  By  secretion  in  tissue  bearing  no  marks  of 
other  lesion,  the  tubercular  matter  being  here 
apparently  deposited  through  excess  of  tubercu- 
lar diathesis. 

It  is  these  last,  the  most  constitutional,  elu- 
sive, and  obscure  forms  of  the  disease,  that  most 
bid  defiance  to  our  therapeutic  means  ;  and  it 
is,  perhaps,  in  great  measure,  in  proportion  as 
these  combine  themselves  with  the  other  form 
that  the  disease  becomes  rapidly  and  certainly 
fatal.  However,  a  predisposition  to  the  chronic 
inflammations  is  scarcely  less  lethiferous,  in 
giving   spring   to   its   irremeable   course  ;    and 


INEFFICACY    OF    MEDICINE.  173 

what  adds  to  the  difficulty  of  checking  it  is, 
that  it  thus  may  run,  as  it  were,  in  a  double 
channel. 

It  would  be  an  interesting,  and,  perhaps, 
practically  instructive  task,  to  trace  the  mode 
of  the  operation  of  the  reputed  occasional 
causes  of  pulmonary  consumption,  in  opening 
one  or  other  of  these  ways  for  the  entry  into 
the  system  of  this  demon  of  destruction.  It  is 
by  this  mode  of  inquiry  alone,  that  a  know- 
ledge of  a  truly  rational  system  of  prophylaxis 
can  be  obtained  ;  and  so,  if  cure  will  ever  be 
within  the  reach  of  human  power,  it  is  to  be 
found  only  by  the  study  of  the  pathology,  and 
of  the  properties  of  external  agents  with  rela- 
tion to  it. 

The  systems,  or  general  plans  in  which  me- 
dicine has  been  arranged,  have  been  always 
framed  on  dogmas  too  exclusive,  and  observa- 
tions too  limited,  to  comprehend  the  varied  anil 
complicated  forms  of  disease.  Nor  is  it  extra- 
ordinary, when  the  mightiness  of  its  extent  is 
considered,  that  few  have  been  the  minds  that 
have  grasped  more  than  a  very  diminutive 
part  ;  few  the  arms  that  have  attacked,  nay, 
the  eyes  that  have  even  seen,  the  many  heads 
of  this  formidable  hydra.  Hastily  running  to 
some  prominent  branch  that  comes  in  our  way, 
we  seize   it  as   a  prototype  of  the  whole  tree, 


174  PHTHISIS    PULMONALIS. 

we  clip  at  its  twigs,  and  blind  ourselves  amongst 
a  foliage,  that  we  see  still 

"  Crescere  per  damnum,  geminasque  resumere  vires  ;" 

whilst  other  branches  grow  untouched,  sup- 
ported on  the  trunk  and  root  of  all,  beyond  our 
reach,  and  even  beyond  our  sight.  Precipi- 
tately burying  ourselves  in  the  umbrageous  in- 
tricacies of  the  foliage,  we  neglect  the  cautious 
and  comprehensive  survey  that  would  teach  us 
that  all  are  centered  in  the  trunk,  that  all  grow 
from  the  roots. 

It  is  no  partial  observer  that  can  form  for  us 
a  philosophical  and  comprehensive  system  of 
medicine.  It  is  not  the  mechanist ;  for,  al- 
though the  body  is  a  machine,  it  is  much  more. 
It  is  not  the  chemist ;  for  although  the  body  is 
a  labratory,  it  is  much  more.  It  is  not  the 
vitalist  ;  for  the  body  is  not  disobedient  to  phy- 
sical laws.  It  is  not  the  humoralist  ;  for  the 
solids  have  also  their  specific  properties.  It  is 
not  the  solidist  ;  for  the  fluids  may  change  of 
themselves,  or  be  changed  from  without.  It 
is  not  the  empyric  ;  for  neither  bodies,  nor  even 
the  body,  are  always  the  same.  Nor  is  it  the 
morbid  anatomist  ;  for  his  dissections  teach  him 
little  of  causes,  or  of  their  relations  with  effects. 
It  is  to  him  who  is  all,  and  none  of  these  ;  who 
views  the  animal  body  as  a  machine  of  its  own 
kind,   obeying  physical    and   chemical   laws  in 


SIGNS    OF    CRUDE    TUBERCLES,   &C.  175 

unexampled  complication,  and  further  disguis- 
ed by  a  combination  with  others  peculiar  to  liv- 
ing structure  ;  and  who,  duly  regarding  all  these 
powers,  seeks,  in  a  change  in  their  relations,  the 
causes  and  the  cures   of  disease  ;    it  is   to  the 

PHYSIOLOGICAL    PATHOLOGIST     that  I    WOUld  look 

for  the  improvement  of  medicine  ;  and  to  the 
combined  exertions  of  many  such,  for  the  ulti- 
mate achievement  of  its  greatest  possible  per- 
fection. 

Section  II. — Physical  Signs. 

In  the  early  stage  of  phthisis,  wThen  the  ra- 
tional symptoms  are  seldom  more  than  those 
of  catarrh,  or  other  pulmonary  affections,  such 
as  cough,  occasional  pain  of  chest,  slight  dysp- 
noea, or,  rather,  tendency  to  anhelation  on  exer- 
tion, &c,  the  presence  of  tubercles,  or  of  the 
indurations  that  precede  them,  will  produce 
physical  signs  more  or  less  appreciable,  accord- 
ing to  the  situation  and  extent  of  the  diseased 
parts.  Thus  the  miliary  indulations,  even  in 
considerable  number,  may  be  scattered  through 
the  tissue  of  the  lung,  without  producing  any 
distinct  diminution  or  change  in  the  resonance 
of  the  chest,  or  the  sound  of  respiration.  But 
if  (and  it  is  the  most  common  case,)  the  indu- 
ration or  tubercular   degeneration  be  partial,  or 


176  PHTHISIS    PIJLMONALIS. 

affect  one  part  much  more  than  others,  then  the 
sounds  of  respiration  and  percussion  will  be 
distinctly  modified,  and  particular  signs  will  be 
produced  in  the  diseased  parts.  What  these 
signs  are,  will  appear  from  the  physical  change 
in  the  organ. 

Where  the  texture  is  solidified  by  the  dis- 
ease, there  the  elastic  resonance  on  percussion 
must  be  diminished,  and  the  sound  of  vesicular 
respiration  more  or  less  obliterated  ;  whilst  those 
of  bronchial  respiration,  and  vocal  resonance, 
are  transmitted  in  an  increased  degree.  Now, 
in  by  far  the  majority  of  cases,  the  principal 
accumulation  of  granular  indurations,  and  of 
tubercular  formation,  takes  place  at  the  apex  of 
the  lung,  which  is  immediately  under  the  cla- 
vicle, and  a  small  space  below  it.  If,  therefore, 
this  bone,  when  struck  about  its  middle,  yields 
a  dull  sound,  or  duller  on  one  side  than  on  the 
other,  it  is  exceedingly  probable  that  the  lung 
is  in  that  part  affected  with  phthisical  degene- 
ration. Great  care  must  be  taken  to  strike 
both  clavicles  at  the  same  point,  for  the  na- 
tural resonance  is  always  less  according  to  the 
distance  of  the  point  struck  from  the  sternum. 
It  is  therefore  generally  expedient,  to  avoid  error, 
to  have  the  parts  uncovered,  and  to  tap  the  two 
clavicles  alternately  at  corresponding  points, 
with  the  middle  finger,  or  the  knuckle  of  the  fore- 


SIGNS    OF    CRUDE    TUBERCLES.  177 

finger*.  When  the  disease  is  extensive,  this 
dulness  of  percussionary  resonance  extends  to 
the  infraclavian  region.  There  is  sometimes 
such  an  accumulation  of  tubercles  also  about 
the  root  of  the  lung  as  to  cause  a  dull  sound  on 
percussion  between  the  scapulae. 

The  stethoscopic  signs  are  more  delicate,  but, 
perhaps,  more  equivocal  tests  than  those  of  per- 
cussion. When  the  tubercular  induration  exists 
in  a  degree  even  less  than  that  required  to 
change  the  percussionary  resonance,  the  re- 
spiratory murmur  will  be  less  distinct  than 
usual ;  or  it  may  present  somewhat  of  a  hissing 
or  bronchial  character ;  and  a  diffused  broncho- 
phony, or  unnatural  fremitus  on  the  exercise 
of  the  voice  will  be  heard  in  the  corresponding 
points  of  the  chest.  Jt  is  when  they  are  more 
manifest    on   one  side    than   on  the  other,  that 

*  The  indications  of  percussion  are  sometimes  deceptive,  from  the  cora- 
hination  of  a  partial  emphysema  with  the  tubercular  or  miliary  induration. 
This  dilated  state  of  the  air-cells  in  the  vicinity  of  indurated  vesicles  and 
bronchi,  which  is  explained  in  the  view  which  I  have  given  of  the  patholog- 
ical causes  of  emphysema,  may  counterbalance  all  effect  produced  by  th8 
indurations.  This  circumstance,  which  was  first  pointed  out  to  me  by 
my  friend,  Dr.  Edwin  Harrison,  must  increase  the  number  of  causes,  in 
which  even  the  physical  signs  arc  negative.  But  by  this  emphysema,  the 
respiratory  sound  in  the  part  will  be  diminished  to  a  degree  inconsistent 
with  the  healthy  resonance  on  percussion.  And  from  the  proofs  which 
Dr.  Harrison  has  given  me  of  the  perfectibility  of  percussion,  as  a  test  of 
the  density  of  parts,  I  do  not  despair  of  finding,  by  its  means,  a  distinction 
between  minuter  gradations  of  difference  than  have  hitherto  been  discovered. 

23 


178  PHTHISIS    PULMONALIS. 

these  signs  are  the  most  certain,  and  existing 
in  points  where  the  respiratory  murmur  is  na- 
turally quite  vesicular  and  free  from  broncho- 
phony ;  as  in  that  part  of  the  subclavian 
region  which  is  close  to  the  head  of  the  hu- 
merus. Towards  the  sternum,  in  the  inter- 
scapular region,  and  in  the  axilla,  these  signs 
indicate  the  probable  existence  of  tubercles, 
only  when  there  is  a  distinct  difference  between 
the  two  sides  of  the  chest  ;  for  the  distribution 
of  the  bronchi  in  these  parts  is  often  such  as 
naturally  to  produce  similar  phenomena. 

Such  are  the  direct  signs  of  tubercles  and  the 
granular  indurations ;  but  usually  there  co- 
exists some  inflammation  of  the  bronchial  mu- 
cous membrane,  which  adds  to,  and,  perhaps, 
somewhat  obscures  these  signs,  by  producing 
different  catarrhal  rhonchi  ;  generally  the  sibi- 
lant and  the  sub-mucous.  It  is  to  this  con- 
comitant bronchitis  that  we  must  ascribe  the 
expectoration  of  the  early  stage  of  consump- 
tion. It  is  usually  scanty,  the  cough  being 
dry  ;  but  sometimes  it  is  pretty  abundant,  and 
consisting  of  pituita,  a  thin  glary  liquid,  which 
generally  indicates  numerous  miliary  granula- 
tions. Hsemoptoe  is  a  frequent,  but  not  con- 
stant precursor  of  phthisis,  and  it  seems,  in 
some  cases,  to  be  caused  by  the  presence  of 
miliary  indurations   and    tubercles   obstructing 


SIGNS    OF    TUBERCULAR    CAVITIES.  179 

the  circulation  in  the  lung,  and  exciting  a  vio- 
lent straining  cough  ;  and  in  others,  in  the  form 
of  pulmonary  apoplexy,  to  precede,  and  pro- 
bably occasion,  the  development  of  the  tu- 
bercles themselves, 

I  think,  on  the  whole,  that  in  the  greater 
number  of  instances,  the  physical  signs  of  this 
stage  of  tubercles  are  such  as  to  give  strong, 
but  not  conclusive,  evidence,  of  an  incipient 
phthisis  ;  and  cases,  that  are  perfectly  free  from 
them  may,  accordingly,  be  regarded  so  much 
the  more  favourably.*  The  practitioner  should, 
however,  be  very  guarded  in  pronouncing  on 
the  nature  of  the  disease  at  this  period :  he 
should  wait  for  the  results  of  repeated  examina- 
tions ;  when,  if  tubercles  are  really  present,  their 
signs  will  generally  become  more  evident  daily, 
and  at  last  of  a  nature  quite  unequivocal. 

It  is  when  the  tubercles,  having  passed  into 
the  softened  state,  become  evacuated  through 
the  bronchi,  and  leave  a  cavity  communicating 
with  them,  that  the  most  characteristic  signs  of 
phthisis  manifest  themselves.  In  the  cavity  thus 
formed,  the  sound  of  the  air  passing  in  and  out 
through  the  liquid  that  it  still  contains,  is  the 
first  sign,  and  constitutes  what  is  called  gar- 
gouillementy  the  gurgling  or  cavernous  rhonchus. 
It  may  be  considered  as  an  exaggeration  of  the 
mucous    rhonchus,    and   it  so  nearly  resembles 


180  PHTHISIS    PULMONALIS. 

that  produced  in  the  trachea  and  large  bronchial 
ramifications,  that  the  symptom  must  be  con- 
sidered doubtful,  when  heard  only  near  the 
sternum,  in  the  axilla,  or  in  the  upper  part  of 
the  interscapular  region  ;  as  it  may  here  be  pro- 
duced in  these  air-vessels.  The  rhonchus  ca- 
vern osus  will  vary  a  good  deal,  according  to  the 
form  and  size  of  the  cavity,  and  the  quantity 
and  spissitude  of  its  liquid  contents.  This  va- 
riety may  be  easily  conceived  without  descrip- 
tion, on  a  consideration  of  the  physical  nature 
of  the  phenomenon.  When  this  cavernous 
rhonchus  is  heard  over  a  considerable  space, 
there  are  probably  several  cavities  communi- 
cating with  each  other,  and  all  containing  a 
considerable  quantity  of  liquid.  When  the  sub- 
ject is  thin,  and  the  cavity  superficial,  percus- 
sion in  its  vicinity  sometimes  produces  a  sound 
something  like  that  of  a  cracked  cup  or  jar, 
struck  with  the  knuckle.  This  is  only  a  modi- 
fication of  the  gurgling,  rendered  somewhat 
metallic  by  the  tinkling  echo  of  the  neighbour- 
ing bronchial  tubes.* 

As  the  liquid  contents  of  a  cavity  are  eva- 
cuated by  expectoration,  the  cavernous  rhonchus 
passes  into  what  is  called  the  cavernous  respira- 

*  This  sound  may  frequently  be  produced  in  the  dead  body  by  per- 
cussion under  the  clavicles  ;  but  it  does  not  here  always  indicate  a  cavity, 
as  its  seat  is  usually  in  the  trachea  and  larger  bronchi. 


SIGNS— CAVERNOUS    RESPIRATION,    &C.       181 

Hon.  The  sound  of  this  is  very  characteristic, 
and  represents  to  the  mind  exactly  the  passage 
of  air  in  a  cavity.  It  has  not  the  diffused, 
slightly  crepitant  sound  of  vesicular  respira- 
tion, is  more  sonorous  and  circumscribed  than 
tracheal,  and  in  different  examples  may  be  very 
perfectly  imitated  by  blowing  into  shells  of  dif- 
ferent sizes.  As  cavernous  respiration  differs 
according  to  the  size  of  the  cavity  in  which  it 
is  produced,  so  the  variety  of  sound  may  be 
taken  as  a  means  of  judging  of  its  size  ;  the  rule 
generally  being  that  the  deeper  and  hollower 
the  sound  of  cavernous  respiration,  the  larger 
is  the  cavity. 

There  are,  however,  other  sources  of  variety 
which  it  is  important  to  notice.  Thus  the 
sound  may  be  like  the  blowing  of  a  bellows,  or 
contracted  almost  to  a  whistle,  according  as  the 
communication  with  the  bronchi  is  free  or  con- 
stricted. If,  with  a  contracted  bronchial  orifice, 
the  cavity  be  of  a  large  size,  particularly  if  lined 
with  a  rigid  false  membrane,  the  respiration  will 
become  amphoric,  or  like  the  sound  produced  on 
blowing  into  a  phial ;  partaking  of  the  character 
and  explanation  of  that  before  described  as  oc- 
curring in  pneumothorax. 

The  thickness  of  the  parietes  of  the  cavity 
do  not,  so  much  as  might  be  expected,  modify 
the   sound  of  cavernous   respiration.      It   may 


182  PHTHISIS    PULMONALIS. 

sometimes  be  heard  distinctly  through  healthy 
tissue  more  than  half  an  inch  in  thickness,  and 
seems  then  more  distant.  When  the  cavity  is 
more  immediately  contiguous  to  the  parietes  of 
the  chest,  the  sound  appears  so  near,  that  the 
auditory  impression  is  like  that  of  blowing  into 
the  ear  itself.  Sometimes  it  comes  only  in  suc- 
cessive puffs,  apparently  interrupted  by  some- 
thing moveable  suddenly  interposed  ;  and  this, 
according  to  Laennec,  occurs  when  a  very  thin 
stratum  of  pulmonary  tissue,  still  spongy,  forms 
the  parietes  of  the  cavity  immediately  opposed, 
but  not  adhering,  to  the  pleura  costalis. 

The  cough,  which  may  be  considered  an  ex- 
aggeration of  respiration,  gives  the  same  va- 
rieties of  character  as  this  latter,  and  some- 
times may  produce  the  signs,  when  ordinary 
respiration  does  not  effect  the  entrance  of  air 
into  the  cavern.  When  the  cavern  has  only 
recently  communicated  with  the  bronchi,  or 
when  it  is  again  nearly  filled  with  sputa,  the  air 
enters  it  and  produces  the  cavernous  rhonchus, 
only  in  the  fuller  inspiration  that  accompanies 
cough.  In  other  cases  this  respiratory  move- 
ment often  renders  the  signs  of  the  existence 
of  a  cavern,  more  certain  and  unequivocal.  In 
a  cavern  that  is  vast  in  size,  and  pretty  simple  in 
form,  and  having  only  a  narrow  orifice  communi- 
cating with  the  bronchi,  the  respiration  may  be 


SIGNS—CAVERNOUS    RESPIRATION.  183 

insufficient  to  have  such  free  access  to  it  as 
would  give  the  sign  of  amphoric  resonance  ; 
but  the  cough  would  not  fail  to  make  its  exist- 
ence known,  by  the  tinkling  echo,  (tinnitus 
metallicus,)  that,  as  in  pneumothorax,  would 
accompany  it. 

Another  most  distinct  and  certain  sign  of  a 
cavity  in  the  lungs  is  furnished  by  the  voice. 
We  shall  best  un  derstand  this  by  referring  to 
what  we  have  formerly  said  on  the  production 
of  the  voice.  Now  that  reverberation  which 
exists  in  the  trachea  and  bronchial  tubes  of 
larger  size,  we  then  observed,  is  so  broken 
down  and  destroyed  in  the  finer  complication  of 
the  cellular  parenchyma,  that  either  the  voice  is 
not  propagated  at  all  through  it,  or  only  a  dull 
diffuse  fremitus  is  heard.  But  if  a  cavity  be 
formed  in  this  parenchyma,  and  a  prolongation 
of  the  bronchial  sounding  board  thus  produced, 
the  voice  will  then  be  heard  in  the  correspond- 
ing part  of  the  chest,  in  a  tone  and  intensity 
more  or  less  perfect,  according  as  the  cavity  is 
adapted  to  receive  and  transmit  the  vocal  reso- 
nance from  the  bronchi. 

When  the  cavity  is  of  moderate  size  and  regu- 
lar form,  and  in  free  communication  with  a  large 
bronchial  tube,  and  either  it  is  very  near  the  sur- 
face of  the  lung  in  contact  with  the  thoracic  pa- 
rietes,  or  the  intervening  tissue  is  rendered  a  good 


184  PHTHISIS   PULMONALIS. 

conductor  by  condensation,  the  voice  is  trans- 
mitted in  the  most  perfect  and  unmodified 
manner,  and  seems  to  be  produced  in  that  spot 
of  the  chest,  seemingly  distinct  from  the  oral 
voice.  This  is  perfect  pectoriloquy.  If  heard 
with  the  sthethoscope,  (which  for  this  purpose  is 
best  adapted  with  the  stopper  in,)  the  sound  of 
the  voice  seems  to  come  through  the  tube,  and 
enters  the  observer's  ear  louder  than  that  which, 
coming  fuom  the  patient's  mouth,  strikes  the 
other  ear  ;  but  the  verbal  utterance  is  never  so 
distinct*.  When  heard,  to  the  degree  just  de- 
scribed, in  parts  where  there  is  little  or  no 
resonance  of  the  voice,  it  proves  (equally  with 
cavernous  respiration)  beyond  doubt  the  exis- 
tence of  a  cavern  communicating  with  the 
bronchi. 

It  is  less  certain  when  occurring  near  the 
sternum,  in  the  axillae,  and  between  the  sca- 
pulae ;  but  if  the  resonance  seems  defined,  passes 
up  the  tube,  and  is  heard  to  this  degree  on  one 
side  only,  there  can  be  little  doubt  even  in  these 
cases :  for  the  natural  bronchial  resonance  of 
these  parts  scarcely  ever  passes  the    tube,   is 

*  How  often  does  the  voice  thus  heard  make  known  a  melancholy 
truth,  the  speaker  never  dreamed  of.  More  than  once  has  it  occurred  to 
me  that  the  very  words,  which;  in  that  delusive  confidence  with  which  this 
malady  enshrouds  its  victims,  ridiculed  my  examination  of  the  chest, 
roundly  saying,  that  nothing  ailed  them  there,  have  belied  their  meaning, 
and  coming  from  the  breast,  have  told  a  far  different  tale  ! 


SIGNS PECTORILOQUY.  185 

generally  diffused,  or  can  be  traced  in  a  line 
along  the  course  of  the  bronchus,  and  is  rarely 
very  unequal  on  the  two  sides.  That  part  of 
the  acromian  region  in  the  angle  formed  by  the 
junction  of  the  clavicle  and  coracoid  process  of 
the  scapula,  may  admit  of  examination  ;  for  if 
the  stethoscope  is  held  nearly  perpendicularly 
on  this  spot,  it  is  out  of  reach  of  the  laryngo- 
phony  heard  in  other  parts  of  this  region.  It 
may  be  held  in  mind  that  natural  bronchophony 
exists  most  in  young  or  thin  subjects  with  a  sharp 
voice,  and  is  generally  slight  in  those  who  are 
stout  made,  and  have  deep  voices  :  but  the 
same  circumstances  are  also  favourable  to  the 
distinct  development  of  pectoriloquy- 

Imperfect  pectoriloquy  is  that  kind  which 
does  not  seem  to  enter  the  stethoscope,  but 
only  to  resound  at  the  end.  This  standard 
of  imperfection  will  not,  however,  always  de- 
note the  uncertainty  of  the  indication  ;  for 
what  is,  according  to  this  definition,  imper- 
fect pectoriloquy,  if  it  occur  where  it  can- 
not be  confounded  with  natural  resonance, 
particularly  if  confined  to  one  side,  may  be 
deemed  a  pretty  certain  indication  of  the  ex- 
istence of  a  cavity:  It  cannot  be  trusted  to 
when  heard  in  the  internal  half  of  the  infracla- 
vian  and  mammary  regions,  the  axilla?  and  in- 
terscapular spaces.  Neither  is  it  always  possi- 
24 


186  PHTHISIS    PULMONALE. 

ble  to  make  this  distinction  in  pectoriloquy,  al- 
though in  the  extreme  degrees  it  is  sufficiently 
apparent ;  for  sometimes  it  seems  only  partially 
to  enter  the  tube,  some  words  being  loud  and 
near,  and  others  in  the  same  sentence  more 
distant :  a  very  bass  voice  scarcely  ever  seems 
to  traverse  the  tube  completely. 

The  smallness  of  the  size  of  a  cavity,  its  im- 
perfect communication  with  the  bronchi,  or  its 
distance  from  the  surface  may  render  pectorilo- 
quy of  the  imperfect  or  doubtful  kind  ;  hence 
these  conditions  being  changed,  (as  often  hap- 
pens in  the  course  of  the  disease)  the  pectorilo- 
quy will  again  become  perfect,  and  vice  versa. 
So  likewise  doubtful  signs  of  a  cavity  may  be 
taken  as  certain,  if  they  arise  suddenly  in  a  spot 
where  such  had  never  before  been  observed  ; 
particularly  if  this  happen  after  coughing  and 
expectoration. 

The  vocal  resonance  is  sometimes  modified 
in  pectoriloquy.  This  not  unfrequently  happens 
when  there  is  a  little  liquid  in  the  cavity,  which 
being  occasionally  raised  in  bubbles,  interrupts 
the  sound  and  gives  it  somewhat  of  a  saltatory 
and  slightly  tinkling  character.  The  vocal 
resonance  is  also  sometimes  alternated  with  " 
puffs  of  cavernous  respiration  ;  for  it  may 
happen,  if  the  communication  with  the  bronchi 
is   small,   that  a  little   increased  force   in    the 


SIGNS— PECTORILOQUY.  187 

passage  of  the  air  through  the  cavern,  may  mo- 
mentarily prevent  the  transmission  of  the  vocal 
vibrations  into  it.  Cavities  of  irregular  form, 
with  partial  septa  and  soft  loose  parietes,  do  not 
produce  so  perfect  a  pectoriloquy  as  those  of 
simple  form  and  smoothly  lined.  Those  of 
moderate  size  perhaps  are  the  best  adapted  to 
produce  the  symptom  ;  but  Laennec  relates  an 
example  where  a  cavity  not  larger  than  a  plum 
stone  produced  a  distinct  pectoriloquy.  When 
the  cavity  is  very  large,  the  communication 
with  the  bronchi  is  often  not  sufficient  to  trans- 
mit the  full  vibrations  of  the  voice  to  the  large 
volume  of  air  in  the  cavity :  In  that  case,  a 
tinkling  echo  accompanies  the  voice,  as  in  pneu- 
mothorax ;  and  this  will  be  more  metallic  and 
resounding,  in  proportion  as  the  cavity  is  ample, 
and  its  parietes  smooth  and  tense.  Percussion, 
as  well  as  the  history  of  the  case,  will  gene- 
rally suffice  to  distinguish  this  case  from  pneu- 
mothorax :  The  sound  is  never  so  clear,  and 
when  mediate  percussion  is  used,  it  may  often 
detect  irregularities  from  the  varied  density  of 
the  subjacent  parts,  which  do  not  appear  in  the 
elastic  drum-like  sound  of  pneumothorax. 

The  pectoriloquy,  produced  in  a  string  or  row 
of  small  excavations,  frequently  presents  much 
of  the  character  of  bronchophony  ;  the  tone  of 
the  voice   being    rendered    more    sharp,    and 


188  PHTHISIS   PULMONALIS. 

somewhat  cracked.  It  may  be  sometimes  diffi- 
cult to  distinguish  between  this,  and  bronchopho- 
ny produced  by  a  partial  inflammation  :  the 
history  may  generally  determine  whether  an 
ordinary  pneumonia  has  taken  place  ;  but  if  an 
inflammation  of  the  intercurrent  kind,  has  been* 
engrafted  on  a  chronic  catarrh,  or  other  affection 
of  the  lungs,  the  symptoms  of  the  latter  may 
have  masked  its  progress,  and  it  may  thus  have 
escaped  observation.  However,  in  this  case 
there  is  generally  some  indication,  either  in  the 
expectoration,  the  remains  or  return  of  the 
crepitant  rhonchus,  or  the  cessation  of  the 
bronchophony,  that  will  be  sufficient  to  dis- 
tinguish the  inflammation.  An  intercurrent 
circumscribed  inflammation  frequently  occurs  in 
lungs  affected  with  tubercles  in  different  stages  ; 
and  in  a  greater  extent  is  not  uncommonly  the 
immediate  cause  of  death.  The  checking  of 
such  inflammations  at  their  commencement  is  a 
principal  object  in  the  treatment  of  phthisis ; 
for,  besides  the  immediately  fatal  effect  that 
they  sometimes  determine,  they  certainly  tend 
to  accelerate  the  progress  of  the  tubercular 
disease.  Hence  the  expediency  of  frequently 
using  the  stethoscope  in  phthisical  cases,  to 
insure  the  detection  of  the  inflammation  at  a 
time  when  a  few  leeches  or  a  counter-irritant 
may  be  sufficient  to   check    it,  without  wasting 


SIGNS    OF    PERCUSSION.  189 

by  depletions  the  little  pittance  of  strength 
that  flight  still  hold  on  existence  a  short  period 
longer.  I  formerly  mentioned,  when  speaking 
of  chronic  catarrh,  that  the  signs  of  an  exten- 
sive dilatation  of  the  bronchi  resemble  those  of 
a  tubercular  cavity  in  phthisis.  Where  a  bron- 
chus is  dilated  at  a  point  to  the  size  of  a 
hazel  nut,  or  even  of  a  plum  stone,  it  is  plain 
that  it  is  physically  capable  of  producing  all 
the  signs  of  a  tubercular  cavity  of  the  same 
size  ;  that  is,  a  coarse  gurgling  rhonchus,  if  it 
contain  liquid  ;  and  cavernous  respiration  and 
pectoriloquy,  if  it  be  empty.  The  case  of  such 
a  dilatation  is  not  common,  but  it  does  occur  ; 
and  as  the  other  symptoms  resemble  those  of 
phthisis,  it  may  be  mistaken  for  this  disease. 
In  time,  however,  a  distinction  may  be  made 
by  the  signs  of  progress  which  the  tubercular 
disease  generally  presents  ;  the  cavity  becomes 
more  extended,  and  causes  signs  of  hollow^ 
more  remarkable  and  extensive  than  dilated 
bronchi  could  produce;  and  not  unfrequent- 
ly  cavities  are  formed  in  other  places.  Dilated 
bronchi  rarely  affect  the  sonoriety  of  the  chest 
on  percussion,  to  the  degree  that  the  engorge- 
ment and  infiltration  about  the  tubercular  ca- 
vities do  ;  nor  can  they  produce  the  other  phy- 
sical signs  of  large  cavities.  The  most  common 
situations    of  dilated    bronchi  are,   in   the   sea- 


190  PHTHISIS    PULMONALIS. 

pular,  mammary,  and  lateral  regions :  the  sub- 
clavian and  acromian  are  the  more  usual  seats  of 
phthisical  signs. 

There  is  generally  some  condensation  of 
tissue  in  the  neighbourhood  of  tubercular  ca- 
vities ;  owing  either  to  other  tubercles  in  a 
crude  state,  or  to  the  effect  of  chronic  inflam- 
mation. Hence  it  seldom  happens  that  the 
chest  recovers  its  natural  resonance  on  percus- 
sion on  the  corresponding  points,  even  after 
the  contents  of  a  cavity  have  been  evacuated. 
When  the  cavity  is  large  and  superficial,  the 
chest  may  sound  well  in  some  places  over  it,  but 
its  resonance  is  irregular,  and  less  elastic,  and 
if  the  other  side  is  still  in  a  healthy  state,  a  re- 
markable but  indescribable  difference  may  be 
both  heard  and  felt  by  the  percussor. 

I  have  mentioned  that  fistulous  cavities  have 
a  tendency  to  increase  in  size  ;  and  this  may  be 
effected  either  by  the  softening  and  evacuation 
of  neighbouring  tubercles, '  or  by  simple  ulcera- 
tion of  the  adjoining  tissue.  Thus  the  symp- 
toms will,  by  the  extension  of  the  disease, 
become  more  and  more  evident,  in  too  many 
cases,  and  soon  put  the  diagnosis  beyond  a 
vainly-hoping  doubt. 

If  the  cavity  be  near  the  surface  of  the  lung, 
and  there  be  no  adhesion  of  the  pleura  at  the 
spot,  there  is  a  chance   of  a  perforation  of  the 


PERFORATION    OF    THE    PLEURA.  191 

pleura  taking  place,  and  producing  a  pneumo- 
thorax. This  accident  is  commonly  mani- 
fested by  the  sudden  occurrence  of  the  general 
signs  of  acute  pleurisy,  caused  by  the  irri- 
tating effect  of  the  tubercular  matter  and  air 
upon  the  pleura.  I  have  already  described 
pneumothorax  produced  in  this  manner  ;  and 
refer  to  what  I  have  there  said  for  an  ac- 
count of  the  physical  signs.  They  are  often 
very  remarkable.  I  have  heard,  in  a  case  of 
this  kind,  an  amphoric  respiration,  so  loud  that 
it  could  be  distinctly  perceived  without  ap- 
plying the  ear  or  the  stethoscope  to  the  chest, 
and,  I  think,  must  have  attracted  my  observa- 
tion, if  I  had  known  nothing  of  auscultation. 

The  evacuation  of  a  softened  tubercle  into 
the  pleura,  without  communication  with  the 
bronchi,  is  of  more  rare  occurrence.  It  gene- 
rally produces  a  pleurisy,  which  is  remarkable 
for  the  suddenness  of  its  attack.  The  effusion 
is  sometimes  accompanied  with  a  disengage- 
ment of  gas  in  the  pleura.  If  the  phthisical 
disease  is  not  far  advanced,  the  effusion  may  be 
absorbed,  and  adhesion  formed,  between  the 
pleura  ;  but  the  shock  of  acute  attack  is  often 
too  great  for  the  wasted  tottering  frame  to 
bear,  and  the  patient  falls  under  it. 

The    expectoration,   in    the    latter  stage    of 
phthisis,  consists  of  softened  tubercles,  and  the 


192  PHTHISIS    PULMONALIS. 

secretion  of  the  tubercular  cavities,  together  with 
a  secretion  from  the  bronchi,  more  or  less  co- 
pious as  the  concomitant  catarrh  is  severe. 
The  expectoration  of  tubercular  matter,  when 
it  can  be  clearly  proved,  may  be  considered  a 
decisive  evidence  of  the  existence  of  phthisis ; 
but  it  does  not  often  present  itself  in  the  sputa  in 
this  unequivocal  form ;  and  it  is  often  a  matter 
of  much  difficulty  to  distinguish  between  it  and 
certain  secretions  of  the  diseased  bronchi,  as 
well  as  of  the  tonsils.  Sometimes  little  por- 
tions of  the  pulmonary  tissue  are  brought  up 
with  the  curdy  and  purulent  matter  of  cavities, 
and  then  the  case  ceases  to  be  doubtful.  The 
pus  and  muco-purulent  matter,  sometimes  tinged 
with  blood,  proceed  more  from  the  inflamed 
bronchi  than  from  the  cavities  themselves.  A 
grumous  liquid,  of  a  grey  or  brownish  colour, 
is  occasionally  seen  in  the  sputa  ;  and  this  seems 
to  proceed  from  the  inflamed  parietes  of  the 
cavities  ;  and  when  they  become  lined  with  a 
fibrocartilaginous  membrane,  this  liquid  be- 
comes more  serous. 

The  formation  of  this  membrane  is  the  effort 
of  nature  towards  the  cure  of  pthisis  ;  and  the 
researches  of  Laennec  have  given  satisfactory 
proofs  that  this  effort  is  not  always  unsuccess- 
ful. The  process  is  simple.  The  vessels  of  the 
cavity   throw  out  a  lymph  ;  this  becomes  con- 


CICATRIZATION    OF    CAVITIES.  193 

verted  into  a  iibro-cartilaginous  membrane, 
which  gradually  increases  in  thickness  until  it 
fills  the  cavity.  The  mass  of  fibro-cartilage 
thus  formed,  in  time  becomes  smaller  and  more 
dense,  drawing  in  the  pulmonary  tissue,  and 
at  length  forms  little  more  than  a  kind  of  cica- 
trix, around  which  the  puckerings  of  the  tex- 
ture are  very  remarkable.  The  signs  of  such 
change  are  the  diminution  and  gradual  cessa- 
tion of  the  symptoms  of  a  cavity  ;  and  if  the 
cavity  was  large,  its  cicatrization  will  produce 
some  contraction  of  the  chest  on  that  side. 

Many,  very  many,  are  the  causes  that  prevent 
the  success  of  this  process  of  nature.  Too 
often,  if  the  lungs  are  not  already  too  exten- 
sively prevaded  by  tubercles  to  leave  enough 
pulmonary  tissue  after  their  evacuation  and 
the  cicatrization  of  the  cavities,  to  support  life, 
the  constitutional  cause  engenders  more  ;  so 
that,  while  some  cavities  are  healing,  other  tu- 
bercles are  generated,  which  may  be  fatal  either 
by  their  present  abridgement  of  the  pulmo- 
nary function,  or  by  the  exhaustion  produced 
by  the  ulcers  entailed  by  their  suppuration. 
Add  the  number  of  contingent  causes  that  may 
prove  fatal  before  this  curative  effort  can  take 
effect ;  haemoptysis,  inflammation,  suffocation 
by  sudden  bursting  of  a  vemica,  perforation  of 
the  pleura,  bodily  exhaustion,  constitutional 
25 


194  MELANOSIS. 

complication — all,  and  many  others  coming  in 
the  deadly  train — and  we  shall  see  how  dimi- 
nutive is  the  chance  of  recovery  from  phthisis. 
The  case  that  should  afford  us  hope  is  that 
on  which  the  pulmonary  organic  disease  seems 
to  be  limited,  the  function  little  embarrassed, 
the  body  not  much  reduced,  and  neither  ha- 
rassed by  a  complication  of  complaints,  nor 
tainted  by  hereditary  diathesis.  Even  others 
of  worse  aspect  may  turn  out  favourably ;  ex- 
perience has  proved  it ;  and  although  in  them 
our  anticipations  cannot  be  brightened  by  hope, 
neither  may  they  totally  be  darkened  by  de- 
spair. And  thus,  if  the  study  of  physical  signs 
shall  often  appal  us  by  discovering  the  dread- 
ful enemy  that  holds  an  object  of  our  care,  it 
has  also  established  the  consolatory  fact,  that  its 
grasp  is  not  universally  relentless. 

There  is  little  need  that  I  should  detain  the 
reader  by  any  notice  of  some  organic  diseases 
of  the  lungs,  of  rare  occurrence  and  obscure 
nature ;  for  whatever  is  known  of  them  will 
suggest  to  him,  now  accustomed  to- the  acous- 
tics of  the  chest,  the  physical  signs  that  are 
likely  to  accompany  them.  Thus  melanosis,  as 
it  runs  a  course  somewhat  analogous  to  that 
of  tubercles,  so  it  will  partake  of  their  physi- 
cal signs*.     In  their  solid   state,  melanose   tu- 

*  Melanose  matter  seems  to  differ  from  that  of  tubercles,   principally  in 
being  composed  of  a  modification  of  the  colouring  matter  of  the  blood, 


HYDATIDS.  195 

bercles  may  produce  dulness  on  percussion  and 
bronchophony  ;  and  after  softening  and  evacua- 
tion, the  usual  signs  of  a  cavern.  The  presence 
of  Ure  melanosed  matter  in  the  sputa  can  alone 
distinguish  the  case  from  one  of  ordinary  tuber- 
cular phthisis. 

The  same  rule  may  be  applied  to  cretaceous 
formations,  scirrhous  and  osseous  degenerations, 
according  to  the  physical  state  which  they  hold 
in  the  lung. 

Hydatids  in  the  tissue  of  the  lung  may  likewise 
produce  bronchophony,  and,  when  evacuated, 
leave  a  cavity,  with  its  usual  signs.  The  possi- 
bility of  distinguishing  any  sounds  produced  by 
the  motions  of  the  animals  themselves,  we  must 
consider  at  least  as  very  apocryphal. 

as  an  altered  albumen  constitutes  the  latter.    The  change  of  the  colour- 
ing matter  is,  in  some  instances,   very  great,  and   proceeds  partly  from 
the  presence  of  a  black  insoluble   matter.     Whether  this  resembles  in 
nature  the   carbonaceous  matter  commonly  found  in  the  lungs,  or  is  allied 
to  the  black  colouring  matter,  pigmentum  nigrum,    abundant   in  the  ne- 
gro, and  scantily  produced  in  parts  of  the  white,  has  not  been  clearly  deter- 
mined.    Let  me  remark  of  the  black  pulmonary  matter,  that  whether  it  be 
derived,  as  seems  probable,  from  the  sooty  particles  that  constantly  float 
in  the  air  where  combustion   is  going  on,  as  suggested  formerly  by  Dr. 
Pearson,  or  be  it  the  product  of  the  body  itself,  it  is  not  extraordinary  that 
the  lungs  should  be  its  peculiar  seat :   for  it  is  perfectly  insoluble  in  any  ani- 
mal fluid  ;  and  if  at  all  arrested  in  the  circulation,  it  must  be  in  the  fine 
vascular  filtre  of  the  lungs,  where  it  will  remain,  and  accumulate.     Like 
the  carbonaceous  matter  of  tattooed  skins,  and  the  insoluble  oxide  of  silver 
in  those  who  become  coloured  by  the  internal  use  of  lunar  caustic,  it  re- 
mains, not  because  there  are  no  textural  absorption  and  reparation,   (an 
opinion  which,  with  his  sagacity,  I  am  surprised  that  Majendie  should  have 
maintained,)  but  because  that  absorption  can  act  only  on  matter  in  a  state 
oi  solution. 


EXPLANATION  OE  THE  PLATES. 


Plate  I. — Construction  oj  the  Stethoscope. 

I  have  already  exposed  »the  general  principles  of  the  con- 
struction of  the  stethoscope  ;  this  plate  will  enable  us  to 
come  to  particulars.  We  have  said  that  the  office  of  this  in- 
strument is  triple  :  1,  As  a  solid  conductor,  to  convey  sounds 
along  its  fibres  ;  2,  As  a  tube  to  contain  a  column  of  air,  through 
which  sounds  are  conducted  ;  3,  As  a  perforated  cylinder  hol- 
lowed at  one  end,  to  concentrate,  in  the  central  canal,  sounds 
produced  over  some  extent  of  surface.  Now  the  perfection  of  a 
stethoscope  will  depend  on  its  being  so  constructed  as  to  fulfil 
best  all  three  parts  of  its  office. 

First,  as  a  solid  conductor.  The  wood  of  which  it  is  com- 
posed should  be  of  straight  and  rigid  longitudinal  fibres,r  un- 
interrupted by  knots  or  inequalities.  The  ends  of  these  instru- 
ments should  be  so  formed  as  to  bring  the  ends  of  these  fibres  in 
close  contact  with  the  parietes  of  the  chest,  from  which  the 
sounds  come,  and  with  the  ear,  to  which  they  are  transmitted. 

The  central  canal,  which  prepares  the  instrument  for  the 
second  part  of  its  office,  does  not  materially  impair  it  as  a 
solid  conductor.  This  canal  should  be  perfectly  straight, 
with  walls  as  even  and  smooth  as  they  can  be  made,  so  as 
to  offer  no  obstacle  to  the  parallel  vibrations,  and  to  reflect 
onwards  the  oblique  ones.  It  is  of  essential  importance  in 
using  the  instrument,  that  it  be  so  applied  to  the  chest  and 
ear,  that  this  central  canal  shall  have  no  communication 
with  the  external  air,  otherwise  the  vibrations  would  be  lost 
outwardly,    instead   of    entering   the    auditoiy    meatus.      The 


CONSTRUCTION    OF  THE  STETHOSCOPE.    197 

end  applied  fb  the  chest  should,  therefore,  he  made  slightly 
concave,  the  better  to  secure  its  exact  and  perpendicular 
apposition  to  it.  The  form  of  the  other  end  must  be  adapt- 
ed to  the  ear  of  the  auscultator.  If  his  ear  be  flat,  it  may- 
be made  flat  or  very  slightly  concave  ;  but  if  the  tragus  and 
antitragus  are  prominent,  it  must  be  made  concave  in  a 
proportionate  degree,  otherwise  they  may  be  pushed  in,  and 
close  the  meatus.  The  end  fits  better  to  most  ears,  by 
being  enlarged  a  few  lines  in  diameter  by  a  horn  or  ivory 
ferule,  or  ring,  glued  round  it ;  or  a  perforated  cap  of  ivory 
or  horn,  as  A  in  fig.  4,  may  be  made  to  fit  closely  on  the 
end  CC. ;  and  that  this  may  impede  the  transmission  of  sound 
from  the  wood  as  little  as  possible,  it  must  be  made  very 
thin,  and  lined  on  the  inside  with  soft  leather,  and  fitting  so 
close  as  to  leave  no  interstices.  I  should  feel  no  hesitation 
in  preferring  the  ring  D,  fig.  3,  if  it  were  not  that  this  cap 
may  be  made  otherwise  useful  as  a  percussion  plate,  in  the 
manner  described  at  p.  22.  This,  and  the  circumstance  that 
the  cap  may  be  removed  in  auscultating  the  sound  of  the 
heart,  <fec.  where  the  solid  fibres  are  the  best  conducting 
media,  may  therefore  give  the  cap  the  advantage  ;  but  both 
of  its  uses  render  it  absolutely  necessary  that  the  perforated 
lamina  covering  the  end  should  be  very  thin.  The  cap  or 
ring  impedes,  rather  than  assists,  the  adaptation  of  the  in- 
strument to  the  ears  of  those  whose  temporal  zygoma  is 
very  prominent ;  and,  in  other  cases,  the  breadth  and  con- 
cavity of  the  ear  end  of  the  stethoscope  must  be  propor- 
tioned to  the  size  and  form  of  the  ear  of  each  auscultator. 
He  should  not  be  hasty  in  choosing  his  instrument,  but 
when  he  has  found  one  exactly  to  fit  his  ear,  he  will  obtain 
a  more  perfect  tact  by  confining  himself  to  it,  than  by  using 
a  variety. 

We  have  lastly  to  consider  the  excavation,  which  enables 
the  instrumemt  to  concentrate  diffused  sounds ;  and,  to  illus- 
trate  the  superior    advantage  of  the    conically   shaped   cxeava- 


198  DESCRIPTION    OF   THE    PLATES, 

tion,  I  have  given,  in  figs.  3  and  4,  sectional  fliagrams,  re- 
presenting the  manner  in  which  the  direct  vibrations  are  re- 
flected. In  the  parabolic  cavity,  fig.  4,  they  are  reflected 
back  on  the  surface  from  which  they  proceeded,  and  cannot 
reach  the  central  canal,  but  by  repeated  reflections,  which 
must  tend  to  impair  their  distinctness  and  intensity,  inas- 
much as  no  surface  is  a  perfect  reflector.  The  sides  of  a 
conical  cavity,  fig.  3,  subtending  an  angle  of  about  25°,  re- 
flect all  the  direct  vibrations,  which  are  the  most  important 
ones,  immediately  into  the  central  canal,  so  that  they  reach 
the  ear  little  impaired  by  reflection.  If  the  angle  be  greater, 
it  will  partake  more  of  the  objectionable  property  of  the 
parabolic  curve,  as  may  be  judged  by  a  reference  to  the 
figures. 

The  perforated  stopper  or  plug,  E  F.  fig.  1,  by  fitting 
exactly  into  the  cavity  G,  reconverts  the  instrument  into  the 
perforated  cylinder.  It  ought  to  fill  the  cavity  completely, 
and  to  hold  tightly  in  it  by  the  flute  joint  H  H,  and  I  I. 
To  render  the  instrument  more  portable,  and  to  facilitate 
its  application  to  some  parts  of  the  chest,  it  is  made  to 
divide  in  the  middle  at  K  K,  with  a  conical  joint,  so  exact- 
ly corresponding  with  that  at  the  end  of  the  instrument, 
that  the  plug  E  F  will  equally  well  fit  the  cavity  K  K  L.  The 
excavated  ends  are  strengthened  by  small  ivory  or  horn 
ferules,  K  K,  without  which  they  would  be  apt  to  split. 
The  wood  should  be  well  dried  before  these  ferules  are 
glued  on,  otherwise  they  are  liable  to  become  loose.  The 
whole  internal  surface  of  the  instrument  should  be  as  even 
and  smooth  as  possible,  in  order  to  perfect  its  reflective 
powers.  Fig.  1,  represents  a  longitudinal  section  of  the 
instrument  in    all  its  proportions,  one  half  the  real  size. 

Such  I  believe  to  be  the  best  construction  to  fit  the  ste- 
thoscope for  its  several  purposes.  Others  may  consider 
portability  or  elegance  of  greater  inportance  than  such 
minute  attention   to    acoustics     as    I    have    held    necessary. 


CONSTRUCTION    OF    THE    STETHOSCOPE.       199 

Fashion  and  fancy  have,  accordingly,  been  at  work  in  devising 
stethoscopes  of  various  forms,  more  or  less  paradoxical. 
The  medical  amateur  may  meet  with  them  in  the  shops,  and 
may  amuse  himself  in  trying  to  find  out  the  principles  of  the 
peculiarity  of  their  construction. 

Fig.  1. — Longitudinal  Section. 

AA.  Stethoscope. 
BBB.  Its  central  canal. 


C.  Its  ear  end. 

D.  Horn  or  ivory  ring. 
EF.  Its  stopper. 

G.  Excavated  end. 

HH.  Flute  joint,  corresponding  with  1 1. 
KK,  KK.  Horn  or  ivory  ferules. 
LLL.  Middle  division. 

Fig.  2. 

A  horn  or  ivory  ear  piece,  or  cap,  fitting  on  the  end  of  the 
stethoscope,  CC.  BB.  inner  surface,  covered  with  soft  leather, 
and  made  convex,  exactly  to  correspond  with  the  concav- 
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202  DESCRIPTION    OF   THE    PLATES 

TABLE  I.— Plate  II. 

In  this  tabular  view  of  the  regions,  I  have  added  a  ge- 
neral summary  of  the  symptoms  of  which  they  severally 
are  the  most  common  seats ;  and  I  have  done  this  more 
with  a  view  to  assist  the  memory  in  a  general  way,  than  as 
giving  any  exact  description.  Assisted  by  Plate  II,  it  gives 
a  ready  view  of  the  situations  of  the  regions  and  the  organs 
within  the  chest,  and  a  summary  of  the  signs  produced  by 
disease. 


Since  my  first  sheets  were  printed,  the  work  just  pub- 
lished by  M.  Piorry,  "  Be  la  Percussion  Mediate"  has  been 
put  into  my  hands  by  my  friend  Dr.  Clark,  to  whom  I  am 
likewise  indebted  for  many  valuable  hints  on  the  arrange- 
ment of  this  work.  The  perusal  of  M.  Piorry's  book,  as 
well  as  some  communications  from  my  friend  Dr.  Edwin 
Harrison,  who  has  with  much  success  applied  his  acute 
mind  to  the  study  of  percussion,  have  convinced  me  of  ad- 
vantages in  mediate  percussion,  greater  than,  from  my  then 
experience,  I  had  expressed  at  the  beginning  of  this  work. 
By  percussion  on  the  pleximeter,  closely  applied  to  the  part 
the  pulmonary  resonance  can  be  elicited  from  parts  which 
yield  no  sound  by  direct  percussion.  Thus,  in  the  scapular 
and  acromial  regions  may  a  sound  be  obtained,  which, 
although  not  equal  to  that  given  by  other  parts  with  thin- 
ner parie*tes,  is  obviously  hollow,  and  proceeds  from  the 
deep-seated  aerial  contents,  and  would,  undoubtedly,  be  ren- 
dered obtuse  by  a  substitution  of  solid  or  liquid  in  the  inte- 
rior. I  must  remark,  however,  that  signs  thus  obtained 
must  not  be  trusted  equally  with  those  of  other  parts ; 
for,   besides  that   the   difference   is   less    marked,   the    sound 


DESCRIPTION    OF   THE    PLATES.  203 

may  proceed,  where  the  parietes  are  so  thick,  not  only  from  the 
part  under  the  point  struck,  but  from  those  in  its  neighbourhood 
likewise. 

Moreover,  M.  Piorry  asserts  that  mediate  percussion  may 
distinguish  differences  in  density,  of  a  deep-seated,  from  that  of 
a  superficial  organ.  Thus,  by  holding  the  pleximeter  lightly, 
and  tapping  gently  on  it,  a  very  slight  pleuritic  effusion  may  be 
detected  by  the  dulness  of  the  sound ;  and  by  using  some  pres- 
sure and  force  in  percussion,  the  resonance  of  the  spongy  lung 
beyond  can  be  elicited,  and  in  this  manner  much  slighter  grada- 
tions of  the  disease  may  be  discovered  than  can  be  detected  by 
immediate  percussion.  This  test  is  equally  delicate  in  distin- 
guishing the  confines  of  the  lungs,  the  situation  and  extent  of  the 
heart,  &c,  much  more  exactly  than  can  be  done  by  the  method 
of  Avenbrugger  ;  and  it  certainly  is  an  important  addition  to  the 
physical  method  of  diagnosis. 


TABULAR  VIEW 

OF    THE 

CHARACTERISTIC  PHYSICAL  SIGNS  OF   DISEASES  OF  THE  LUNGS 

AND  PLEURA. 


TABLE  II. 

Physical  Signs  in   the  Part  Affected. 

Pectoral 

Vocal    reson- 

Disease. 

sounid  on  per 
cuss  on. 

Respiratory  Sounds. 

ance. 

Sputa. 

Acute  Bron- 

Sometimes 

Weak  in  parts  ;  accom- 

Natural. 

Mucous,  at 

chitis. 

slightly  dimi- 

panied by  a  rhonchus,  first 

first  thin,    af- 

nished. 

sonorous  or  sibilant,  after- 
wards   mucous. .    Towards 
the  end,  respiration  some- 
times   inaudible    in     some 
spots. 

Weak  in  parts,  or  irregu- 

terwards 
viscid. 

Chronic 

Slightly  im- 

Natural. 

Mucous  ; 

Bronchitis. 

paired,   if  the 

lar,  with  mucous  rhonchus. 

Bronchopho- 

sometimes 

catarrh  is  ex- 

ny, or    even 

purulent, 

tensive. 

pectoriloquy 
in  dilated 
bronchi. 

sometimes 
streaked  with 
blood. 

Pituitous 

Partially  im- 

Weak, with  sonoro  us,  si- 

Natural. 

Pituitous. 

Catarrh. 

paired. 

bilant,  and  mucous  rhonchi. 

Dry  Catarrh. 

Natural. 

More  or  less  extinct    in 
parts.     Occasional  sibilant, 
sonorous,  and  dry  mucous 
rhonchi. 

Natural. 

A  pearly  thick 
mucus. 

Spasmodic 
Asthma. 

Sometimes 

Usually  weak,  or  even  in- 

Natural. 

Little  or  none. 

impaired. 

audible  ;    but  distinct,   and 

even  puerile,    immediately 

after  holding  the  breath   a 

while. 

Peripneu- 

mony. 

A  little  im- 

Weak,     with     crepitant 

Natural. 

Viscid,  of  a 

1st  stage. 

paired. 

rhonchus. 

rusty  hue. 

2d  stage. 

Quite   dull. 

Bronchial,  with  crepitant 

Broncho- 

Rusty, &  very 

rhonchus. 

phony. 

viscid,  or  none 

3d  stage. 

Quite  dull. 

None ;  except  sometimes 
a  coarse  mucous  rhonchus. 

None. 

Sometimes 
purulent, 
sometimes 
brown  and 
watery,   often 

Emphysema. 

Unnaturally 

Diminished,    and    some- 

Natural. 

none. 

clear. 

times  almost  extinct.  Cough 
accompanied    by  a  sibilant 
rhonchus. 

Sometimes 
mucous ;  of  a 
dirty  grey  co- 

QSdema. 

Dull,  if  the 

Weak,  with  subcrepitant 

Sometimes 

lour. 

effusion  be  ex- 

rhonchus. 

slight  bron- 

Slightly viscid 
and  colouress 

tensive. 

chophony. 

Pulmonary 

Dull,  if  near 

Extinct    in    the    haemop- 

Occasionally 

pituita. 

Apoplexy. 

the  surface, 

toic  spots  ;  a  rhonchus,  first 

broncho- 

Blood, or 

and  extensive 

.subcrepitant,afterwards  mu- 
cous, around  them. 

phony. 

bloody  mucus. 

Pleurisy. 

Quite  dull. 

First  weak  ;    afterwards 

At  first  aego- 

None  ;  01  ca- 

extinct,  except  at  the  root 

phony  ;  after- 

tarrhal. 

• 

of  the  lungs. 

wards  none. 

TABLE  CONTINUED. 


Disease. 

Physical  Signs  in   the  part  Affected. 

Sputa. 

Pectoral 
sound  on  per- 
cussion. 

Respiratory  Sounds. 

Vocal  reson- 
ance. 

Pleuropneu- 
monia. 

Hydrothorax. 

Pneumotho- 
rax, 

a.  Simple. 

b.  With 
fistulous  com- 
munication 
with  the 
bronchi,  and 
IiquidefFusion. 

Phthisis. 

a.  Stage  of 
grey  indura- 
tion, and 
crude  tuber- 
cles. 

b.  Stage  of  e- 
vacuation  of 
the  softened 
tubercles. 

Quite  dull. 
Quite  dull. 

Unnaturally 
clear. 

Dull  in  the 
dependent 
parts  ;   very 
clear  above. 

Impaired,  if 
the  accumula- 
tion be  exten- 
sive. 

Unequal. 

At  first  weak,  with  cre- 
pitant rhonchus  ;  then  bron- 
chial, afterwards  extinct. 

Weak  or  extinct,    accord- 
ing to  the  quantity  of  the 
effusion. 

Weak  or  extinct,  accord- 
ing to  the  quantity  of  air 
effused. 

Ditto.     Succession  of  the 
chest  produces  sound  of  fluc- 
tuation.     Respiration    and 
cough,  sometimes  attended 
with    amphoric    resonance 
or  metallic  tinkling. 

Weak,  or  somewhat  bron- 
chial, if  the  accumulation 
be  extensive. 

Cavernous  rhonchus,  re- 
spiration, and  cough. 

Buzzing 
aegophony. 

iEgophony, 
when  the  effu- 
sion is  scanty. 

Generally 
none  ;    rarely 
metallic  tink- 
ling. 

Metallic 
tinkling. 

Diffused 
bronchopho- 
ny, if  the  ac- 
cumulation be 
extensive. 

Pectoriloquy, 
when  the  ca- 
vity is  empty. 

As  in  perip- 
ncumony. 

Various. 
Various. 
Phthisical. 

Sometimes 
catarrhal  and 
scanty,  some- 
times pituit- 
ous,    some- 
times bloody. 

Muco-puru- 
lent  ;    puru- 
lent ;    tuber- 
cular ;    curdy 
matter  ;    san- 
guinolent  ;<^l 
Errey  or  brow- 
nish grumous 
liquid.